This document provides details of a 59-year-old Asian male who underwent CABG surgery. He has a history of diabetes for 1.5 years and hypertension since 2014. He previously underwent PTCA-LAD in 2018. The document outlines his pre-operative, intra-operative, and post-operative course, including monitoring parameters, lab values, medications, and progress. It summarizes his hospital stay and treatment before being discharged on stable condition on April 27th.

1. CASE
PRESENTATION
BY,
Sri sharika kumar
1

2. 2
Previous procedure underwent
was PTCA – LAD done on
2018.

3. 3
Current procedure planned

4. CASE SUMMARY
An Asian 59 year old male was shifted to our KMCH hospital on
20/04/19 from Lakshmi super speciality hospital Palakkad, for CABG
surgery. He is a diabetic patient for the past 1½ years (since 2016)on
treatment and hypertensive patient too since 2014. previous surgery
PTCA-LAD done on 2018.
4

5. PREVIOUS DRUGS PRESCRIBED IN LAKSHMI HOSPITAL BY
Dr.P.B.jayagopal MBBS, MD, DM, DNB, FACC, FESC, FCSI, FICC(cardiologist).
Dr.sakalesh pattil DNB, (med) DNB (cardiologist).
DRUGS:
Tab. Roseday A 20/75 - 0-0-1
Tab. Brilinta (90mg) - 1-0-1
Tab. Gemer (2mg) - 1-0-1
Tab. Nexovas (10mg) - 1-0-0
Tab. Pantodac (20mg) - 1-0-0
Tab. Tenglyn (20mg) - 0-1-0
Tab. Betaloc (25mg) - 1-0-1
Tab. Monit GNT (6.4mg) - 1-0-1
Tab. Flavedon MR (35mg) - 1-0-1
Tab. Cefoclox CL (6) - 1-0-1
For 2 days . 5

6. PATIENT DEMOGRAPHIC
• Ip no: E94857.
Age:59 years.
Gender:Male.
Date of admission:20/4/19.
Primary doctor: Dr.prashant vaijayanath,
Dr.suresh kumar and
Dr.Vidhya.
6

7. SUBJECTIVE INFORMATION
BMI : 34.3 obese BMI.
MEDICATION USED FOR PAIN : INJ.dextomid(200/50) 7ml/hr.
7
Height : 161cm.
Weight : 89 kgs.

8. 8
Present surgical procedure:
CABG×5 done on 23/4/19.
Past diagnosis:
DM-one and half years on treatment.
Hypertension.
Previous surgery:
PTCA-LAD done on 2018.
Behavioural history:
No smoking ,No drinking.
Physical examination :
conscious ,oriented and afebrile .

9. OBJECTIVE INFORMATION
• BLOOD TEST :
Biochemistry Patient value Biological reference range
Sodium serum 139 133 to 145mEq/L
potassium 4.1 3.3 to 5.1mEq/L
Blood urea 17 10 to 50 mg/dL
Creatinine 0.8 0.7 to 1.2mg/dL
HbA1c 5.8 4.2 to 5.9%
PT 13 11 to 16 seconds
INR 1.17
TSH 4.86 0.27 to 4.2mu/mL
9

10. 10

11. Complete blood cell
count
Patient value Biological reference
range
PCV 39.3 40 to 52%
MCHC 36.2 31 to 36g/dL
11
CVS- S1,S2 +
Abdomen – soft

12. URINE ANALYSIS
MACROSCOPY MICROSCOPY
OBJECTIVE OBSERVATION
Colour straw
Appearance clear
Specific gravity 1.015
Reaction Acidic
Albumin ++
Sugar Not detected
Acetone -ve
Bile salts -ve
Bile pigments -ve
Urobilinogen Slightly increased
OBJECTIVE OBSERVATION
Pus cells 1-2 cell /HPF
RBC NIL
Epithelial 0-1 cells/HPF
Bacteria Nil
Crystals Nil
Cast Nil
Flagellates Nil
others Nil

13. Diagnostic tests
• Lab investigations :
ECG 12 lead ,std placement
- prolonged PT interval
- non-specific intraventricular conduction delay.
• DOPPLER study of carotid &vertebral arteries- normal impression.
• DOPPLER study of rt. Lower limb arteries –normal impression.
• DOPPLER study of lt. lower limb arteries- normal impression.
no evidence of stenosis or occlusion.
13

14. Progress notes
• On admission :
14
Date & Time Complaints investigations Therapy & Plan
20/04/19 @ 9am DM & HTN To take test of
HbA1c ,BP
Tab.gemer 2mg
Tab.Tenglyn 20mg.
Tab.betaloc 25mg.
20/04/19 @ 11am IHD
CAG- severe TVD
ECHO –EF 72% Do the routine CV
doppler .
Inj.heparin -5000 U
IV is given.

15. 15
Next day of the admission :
Date & Time Investigations Therapy & Plan
21/04/19 ECHO: LVH with GRADE I
Trivial MR
Normal CV systolic function
.EF- 60%
CABG Surgery .

16. 16
On 22/04/19 : previous day of operation .
Dr. Vidhya
Lab values
&investigations
Therapy Plan
HbA1c – 5.8 % Tab . Gemer 2mg
Tab . Tenglyn 20mg
Insulin Human actrapid
Morning and night
Only on morning.
Continue premeal +2 am (150 sliding scale ).
Creatinine -0.7 Normal in level Maintained the same level.
Feet fungal infections
No pain /ulcer
Tab.cefoclox
CL(cefpodoxime200mg+clavulanic
acid125mg)
Antibiotics are continued.

17. ON THE DAY OF OPERATION
• 23/04/19 :
Impaired gas exchange :
monitored the spo2 level in ABG ,
ET1oral suctioning is done,
O2 given through ventilator.
Risk for infection :
Handled in aseptic technique ,
Antibiotics are given.
17

18. Pre operative analysis
• EF- 50%
• Hb- 6.4gm/Dl.
• Potassium- 41mEq/dL
• Urea – 17 mg/dL
• Cr- 0.8
• ECHO:
1) trivial mitral and tricuspid regurgitation , no RWMA , LVH with grade –I
diastolic dysfunction .
18

19. Progress notes
Post operative condition
19

20. 20
ABG ON 23/04/19:
BLOOD GAS ANALYSIS 19:08 14:08
BARO 726.7 mmHg 725.3mmHg
TEMP 37.0°c 37.0°c
FiO2 0.210 0.210
pH 7.410(7.350-7.450) 7.389(7.350-7.450)
pCO2 39.2 mmHg (35.0-45.0) 41.2mmHg(35.0-45.0)
pO2 104.4mmHg(+)(80.0-100.0) 10.32mmHg(+)80.0-100.0)
Na 132.3mmol/L(-)(135.0-148.0) 137.3mmol/L
K 4.10mmol/L(3.50-4.50) 3.81mmol/L
Cl 96.2mm0l/L(-)98.0-107.0) 102.6mmol/L
Ica 1.005mmol/L(-)(1.120-1.320) 0.987mmol/L
HCT 42.5% 36.2%

21. 21
Post operative monitoring:
Monitoring values Arterial lining On flow drugs
HR- 74/mts
BP- 110/50mmHg
CVP- 8mmHg
Spo2- 95% with
ventilator support.
Right internal jugular line× 4 lumen
Right radial arterial line
Left peripheral line ×1
ICD× 3 tubes connected with negative
suction vaccum drain XI .
Inj. Noradrenaline 4/50 -2.5ml/hr
Inj. Dextomid -7ml/hr
Inj.human actrapid -3units/hr
IVF -100cc/hr
Physical examination:
pupils are equally reacting to light, peripheries are slightly warmth , pedal
pulse felt, pain score 0 .

22. 22
@5:00 pm RBS -164 mg/dL
On 23rd of April:
@7pm
MONITORING
PARAMETERS
VALUES
HEART RATE 80/min
BP 140/80mmHg
CVP(central venous pressure) 2 to 8mmHg
Spo2 -100% with ventilator support.
INJ. nor adrenaline 4/50 3.5ml/hr
INJ. Dextomid 7ml/hr
INJ. Human actrapid 1units/hr
IVF 100cc/hr on flow

23. 23
@7:30 pm
MONITORING PARAMETERS VALUES
HEART RATE 92/mins.
BP 152/82mmHg.
CVP(central venous pressure) 3mmHg.
PEEP 5.
FiO2 40%
No bed sore or skin pealing ,pedal pulse felt
INJ. Nor adrenaline
INJ. Dextomid 7ml/hr
INJ. Human actrapid 1unit/hr
IVF plasmolyte A+8 units of h.actrapid 100ml/hr on flow

24. Post operative analysis
• No RWMA.
• Normal LV systolic function with grade I
• EF-50%
• LVH (+)
• Trivial tricuspid regurgitation .
• No pulmonary artery hypertension
• No pericardial effusion /clot.
• Trace pericardial effusion noted.
24

25. 25
@8:00 pm
MONITORING VALUES THERAPY
RBS -198mg/dL Inj.H. Actrapid 1unit/hr to be continued.
@9:00 pm
steam inhalation is given
@2:00 am
MONITORING VALUES THERAPY
RBS- 220mg/dL Inj. Human actrapid 3units /hr.
@4:00 am
Abdominal girth – 107 & No bed sore and skin pealing.
( to determine the abdominal fat or visceral fat)
or
( any enlargement seen after operation.)

26. 26
24th April :
@5:00am
steam inhalation given.
@6:00am
chest physio given , breathing and coughing exercise given
PATIENT RAISED ONE BALL .
@7:00
no bed sore and skin pealing.
Monitoring parameters Values
HEART RATE 78/mins
BP 112/62mmHg
CVP 4mmHg
Inj. Nor adrenaline 4/50 2ml/hr
Inj. Dextomid 200/20 2ml/hr
Inj. H.actrapid 40/40 1 unit/hr
IVF plasmolyte A 100ml/hr on flow

27. 27
@7:35 am
peripheries warmth pedal pulse felt
MONITORING PARAMETERS VALUES
HEART RATE 86/mins
BP 142/74mmHg
Inj. NA 2ml/hr
Inj. Dextomid 2ml/hr
Inj. Human actrapid 1 unit/hr
IVF plasmolyte 100cc/hr on flow
@8:00 am
MONITORING VALUES THERAPY
Blood sugar-207 Inj. H actrapid 3units/hr

28. 28
@9:40 am
spirometry exercise given,patient raised one ball (respirometer).
@11.25 am
Tablets were adviced by Dr,prashanth vaijanath
Tab. Dytor-20mg/OD.
Tab. Plavix -75 mg/OD.
@1:00pm
Inj. Dextomid 2ml/hr
IVF plasmolyte A ,V1 70cc/hr on flow
Monitoring parameters Values
HEART RATE 80/mins
BP 116/70mmHg
CVP(central venous pressure) 7mmHg

29. 29
Time parameters Lab values Therapy
@1:30 pm HEART RATE 95/mins
@1:30 pm
@6:00 pm
@7:00 pm
@12: 30 pm
BP
-
BP
-
138/80mmHg
-
109/65mmHg
-
-
Inj. Lasix 10mg
Tab. Dytor 20mg.
@4:00 pm RBS 169mg/dL Inj. H. actrapid 2 unit.
On 24th April 2019:
saO2 – 100%
Cvp- 3cm H2O.
inj. Dextomid 20ml/hr
plasmolyte A on flow

30. 30
25th April @10:30 am :
BP-122/70 mmHg.
Spo2-99%
HR-100/mins.
PLAN:
Tab. Betaloc 25mg
To remove all lines and tubes.
Mobilise the patient , & shifted to the ward.
26th April @ 7:00 am :
blood sugar -146mg/dL.
PLAN:
stop actrapid correction scale ,monitor fasting pre lunch,pre dinner
Tab. gemer 1mg (1-0-1) is given.

31. 31
27/04/19 on the day of discharge :
@6:00am Neomatic enema 20ml
On discharge inj.spizef ,inj . Augmentin , inj. Nacfil, forms are changed to tablet forms on 26/04/19.
STOPPED DRUGS:
Inj. Edgpar on 25th
Inj. Deriphylline on 24th
Inj. Rantac changed to tablet form on 24th
inj. Tramadol stopped on 25/04/19.

32. 32
Date Time Values Medication Therapy
23/04 5:00 pm RBS- 164mg/dL Inj.H actrapid 2units .
24/04 FBS- 207 mg/dL Inj.H actrapid 3 units
25/04
4 pm
7pm
FBS- 200mg/dL
129mg/dL
159mg/dL
Inj.H actrapid 2 units.
-
Inj. H actrapid 2units .
26/04 2am 164mg/dL Inj.H actrapid 2 units
26/04 7am 146mg/dL -
26/04 12 pm
9:33 am
209mg/dL
FBS- 146mg/dL
Inj.H actrapid 4 units
-
27/04 FBS 147mg/dL -
DIABETIC CHART:

33. Physician’s drug therapy plan
33

34. DRUGS CHAT
DRUG
(DOSE/RQUTE/FREQ)
TIME 23/4/19 24/4/19 25/4/19 26/4/19
CEPHALOSPORIN
ANTIBIOTICS
INJ.SPIZEF(2GM)
I.V 23/4/19 (BD)(Cefuroxine)
10 AM
10 PM







TAB. CEFTUM(500MG)
26/4/19/ORAL/BD
8 AM
8 PM
BETA-LACTOMASE
INHIBITORS
INJ.AUGMENTIN(1.2GM)
I.V 23/4/19 (TID)
(amoxycillin /clavulanic acid)
6AM
2PM 





34

35. 35
DRUG
(DOSE/ROUTE/FREQ)
TIME 23/4/19 24/4/19 25/4/19 26/4/19
HISTAMINE 2(H2)
RECEPTOR BLOCKER
INJ.RANTAC (50 MG)
I.V 23/4/19(TID)
(ranitidine)
6 AM
2 PM
10 PM


CHANGE TO
TAB
TAB.RANTAC 150 MG
24/4/19 (TID)
6 AM
2 PM
8 PM




MUCOLYTIC AGENT
INJ.NACFIL(1,2GM)
I.V 23/4/19 (BD)
N- ACETYL CYSTEINE)
8 AM
8 PM
---







36. 36
DRUG
(DOSE/ROUTE/FREQ)
TIME 23/4/19 24/4/19 25/4/19 26/4/19
ANALGESICS
&ANTIPYRETICS
INJ.EDGPAR (1GM)
I.V 23/4/19 Q6H
(Paracetamol)
12 AM
6 AM
12 PM
6 PM 







STOPPED ON
25/4/19
TAB.DOLO(650 MG)
24.4.19/ORAL/(TID)
8 AM
2 PM
10 PM


OPIOD ANALGESICS
INJ.TRAMADOL(75MG)
I.V 23/4/19( Q6H)
(tramadol)
12AM
6 AM
12 PM
6PM
OT 100 mg








STOPPED ON
25/4/19

37. 37
DRUG (DOSE/ROUTE/FREQ) TIME 23/4/19 24/4/19 25/4/19 26/4/19
ANTI PLATELET DRUG
TAB.ECOSPIRIN(150 MG)
ORAL/ 24/4/19 (OD)
Aspirin
2 PM  
STATINS
TAB.TONACT (80 MG)
24/4/19 (HS)
Atorvastatin
8 PM  

38. 38
DRUG TIME 23/4/19 24/4/19 25/4/19 26/4/19
DIURETICS
TAB.DYTOR (20 MG)
20 MG 24/4/19 (OD)
Torasemide
8 AM   
ANTICOAGGULANTS
TAB. PLAVIX 75MG
24/4/19 (OD)
clopidogrel
2PM  

39. 39
DRUG TIME 23/4/19 24/4/19 25/4/19 26/4/19
BETA BLOCKERS
TAB.BETALOC (650 MG)
ORAL /25/4/19 (BD)
metoprolol
8 AM
8 PM 

PENICILLIN –
ANTIBIOTICS
TAB. AUGMENTIN
625 MG /ORAL /26/4/TID
Amoxycillin/clavulanate
8AM
2 PM
8PM
SECRETOLYTIC

40. 40
DRUG TIME 23/4/19 24/4/19 25/4/19 26/4/19
SYP.MUCOLITE
10 ML/ORAL/26/4/19
TID
Ambroxyl
8 AM
2 PM
8 PM
SOS
LAXATIVES
SYP.DUPHALAC
30 ML /ORAL /26.4.19
/OD( lactulose)
9 PM
SOS

41. 41
DRUG TIME 23/4/19 24/4/19 25/4/19 26/4/19
XANTHINES
INJ.DERIPHYLLINE( 2 ML)
I.V 23/4/19 (TID)
(Etiophylline /theophylline)
6 AM
2 PM
10 PM 


STOPPED ON
24/4/19
CORTICOSTEROIDS
NEB.DUOLIN AVAIL(3 ML)
2.5 ML 23/4/ 19 (T ID)
Salbutamol /ipratropium bromide
6 AM
2 PM
10 PM








42. Pharmacist work up of drug therapy
42
1) Loop DIURETICS:
some of the water pills can cause dehydration and can also lead to swelling and
inflammation of the kidneys. Metabolic alkalosis can occur 2nd to loop diuretics use in a few days .
one is due to increased distal delivery of sodium ions .
this pump exchanges sodium ions for hydrogen ions , the loss of which can lead to alkalosis.
this same pump also exchanges sodium ion to potassium ion ,leading to hypokalemia.

43. 43
DRUG INTERACTING
DRUG
SEVERITY RISK RECTIFICATION
Cefuroxime Diuretics(torsemide) Moderate Adverse renal effects. ACE inhibitors can be
given.
Ranitidine Beta blockers Mild Inhibits the drug
hepatic metabolism .
Time adjustment
should be done.
Beta adrenergic
blockers
Metoprolol Mild Elimination half life of
metoprolol increased
from 4.4 to 6.5 hrs.
Timing adjusted.
Acetaminophen Aspirin Only when
dose exceeds
Inhibits the antiplatelet
effects.
Nacfils can be used for
acetaminophen
poisoning ,Dose
dependent.
salbutamol diuretics Moderate Hypokalemia Potassium supplement
such as Syp. Poiklor
can be prescribed.
DRUG – DRUG INTERACTION CHART:

44. About Drug Information & Interactions
• There is no severe drug - drug interactions and no drug disease and drug
food interactions where found.
• Clopidogrel will increase the risk of bleeding . Causion should be taken.
(INR monitoring should be done).
44

45. Pictograms for patient’s better
understanding on the diet plans
45
Dietary
Approaches to
Stop
Hypertension
And also for cardiac
response towards
medicine and control.

46. 46
Patient is obese so diet should be advised :
Low Fat,Salt Restricted and Diabetic Diet.
Patient counselling:
1) Avoid heavy lifting and extremes of shoulder
movements.
2) Not to strain for 3 months (until the sternum
fixes/heals completely post operative).
3) wound infection persist within 14 days of after
surgery should be insisted.
4) cardiac rehabilitation should be insist and encouraged.
5) educating do’s and don’ts to the patient in a simple
manner.

47. CARDIAC REHABILITATION
• Improvement in the heart function
• Lowering of the heart rate at rest & during the exercise.
• Reduced risk of dying.
EXERCISE , ANXIETY , DEPRESSION – REDUCED risk .
• Not to eat :
sodium , saturated & transfats , added sugars .
47

48. 48
For a busy schedule person :
FOR REDUCING THE WEIGHT –
Take the stairs instead of the elevator.
Walk during the breaks.
Eat with a time gap.
Type of exercise :
Aerobic exercise , walking , jogging , cycling .

49. PATIENT ON DISCHARGE
49
MEDICATION DOSE MORNING AFTERNOON EVENIN
G
NIGH
T
A/B DURATIO
N
TAB.CEFTUM 500mg 1 0 0 1 AF 5 days
TAB.AUGMENTIN 625mg 1 1 0 1 AF 5 days
TAB.ECOSPRIN 150mg 0 1 0 0 AF 10 days
TAB.TONACT 80mg 0 0 0 1 AF 10 days
TAB.PLAVIX 75mg 0 1 0 0 AF 10 days
TAB.DYTOR 20mg 1 0 0 0 AF 10 days
TAB.BETALOC 25mg 1 0 0 1 AF 10 days
TAB.IVABRAD 5mg 1 0 0 1 AF 10 days
TAB.NACFIL 1.2mg 1 0 0 1 AF 10 days
TAB. ALPRAX 0.5mg 0 0 0 1 AF 10 days

50. 50
MEDICATION DOSAGE MORNIN
G
AF EVENIN
G
NIGHT A/B DURATION
TAB.DOLO 650mg 1 0 1 0 AF 10 DAYS
TAB.RANTAC 150mg 1 0 0 0 BF 10 DAYS
SYP.MUCOLITE ---- 10 ml 10
ml
0 10 ml AF 10 DAYS
SYP.DUPHALAC ---- 0 0 0 30 ml AF 10 DAYS
PHARMACIST INTERVENTION:
diabetic drug is missing in this discharge summary medications.
Tab.gemer 2mg can be prescribed.

51. PATIENT COUNSELLING ON
DISCHARGE MEDICATION
• Tab. Ecospirin 150mg is for preventing the progression of heart blocks
(clots) and to prevent the platelet aggregation.
• Tab. Plavix is an antiplatelet , for proper blood flow.
• Tab.dytor is used for treating BP , dose should be taken appropriately. (if
dose exceeds diuresis will occur) only should be taken on morning ,because
urination often will be present. Not to take on morning.
• Tab. Rantac should be taken on empty stomach (before breakfast or any
food intake).
51

52. • Tab. Tonact must be taken at night ,insisting the patient about its action and
effectiveness. (because the cholesterol making enzyme is more active at night ) &
its half life is short (less than 6 hours).
• Antibiotics are should be taken for the proper duration of time ,must educate
the patients (to avoid the resistant to the drug and species)on later use.
52

53. 53