The document presents a case study of a 69-year-old male patient with hypercholesterolemia, diabetes, hypertension, and ischemic heart disease, outlining his medical history, current medications, lab results, and a pharmaceutical care plan to monitor and control his conditions through lifestyle changes, medication management, and treatment goals. Risk factors for his conditions included obesity, family history, smoking, physical inactivity, and age. His diseases were assessed as uncontrolled despite medications due to additional risk factors.

1. Pharmaceutical Care Plan
Hypercholesterolemia Cases Presentation
Prepared By:
Marwah Mamoon
2011-2012

2. What is cholesterol?
- Cholesterol is an essential substance manufactured by most cells
in the body. it is used to maintain cell wall integrity and for the
biosynthesis of bile acids and steroid hormones.
Other major lipids in our body are triglycerides and phospholipids.
Since cholesterol is a relatively water-insoluble molecule,
it is unable to circulate through the blood alone, so it
along with triglycerides and phospholipids are packaged in a
large carrier-protein called a lipoprotein . Lipoproteins
are water soluble, which allows transportation of the major lipids in
the blood.
-Cholesterol is transported from the arterial wall or other extra-
hepatic tissues back to the liver by HDL. Esterified cholesterol from
HDL can be transferred to apolipoprotein B-containing particles in
exchange for triglycerides. Cholesterol esters transferred from HDL
to VLDL and LDL are taken up by hepatic LDL receptors or delivered
back to extra-hepatic tissue where metabolized to LDL. LDL can be
cleared by hepatic LDL receptors or can enter the arterial wall &
contributing to atherosclerosis.

3. Hypercholesterolemia
- Defined as elevated total cholesterol, low-density
lipoprotein (LDL) cholesterol, or triglycerides; a low high-
density lipoprotein (HDL) cholesterol; or a combination of
these abnormalities.
- Hypercholesterolemia is typically due to a combination
of environmental and genetic factors.
- Environmental factors include: obesity and dietary
choices.
- Genetic contributions are usually due to the additive
effects of multiple genes however occasionally may be
due to a single gene defect .

4. Case Presentation
Step no.1: Gathering information & creating patient database
A.H. male patient is 69 years old , weight 85 kg,
height 163cm ,BMI (31.9 “he is obese”) ,married; has
3 boys & 2 girls, his work is farmer, he lives in
Hawler –Shortan, he admitted to Rizgari hospital in
31/10/2011 ,his phone number is 07502747735, the
name of his physician is Mohammad Sader aldin
Mahmoud, Complain of chest pain on exertion for 1
week duration.
Present illness: A known case of Diabetes mellitus of
4 years duration , Ischemic heart disease of 2
years,Hypertension of 1.5 year , present with chest
pain on exertion lasted for 5-10 min associated with
sweating ,relived by rest & sublingual nitroglycerin.

5. PAST MEDIACL HISTORY
1- Illness:
Item 1 - Diabetes Mellitus.
Item 2 - Ischemic heart disease.
Item 3 - hypertension.
- Heavy Smoker for 17 years duration, quit
Item 4
smoking since 2003, 2pockets/ day.
2-Surgical history: Nil
3- Family history:+ ve family history of
Diabetus mellitus and IHD
4- Social history: ex-smoker,
not drinker.

6. Drug History (dhx)
1-clopidogrel 75 mg 1X1
tab.
2- Atorvastatin 10mg 1X1
3- bisoprolol 5mg 1X1
4- lisinopril 5mg 1X1
5- Metformin 850mg 1x2
6- Glibenclamide 5mg 1x1
7- Aspirin 100mg 1x1
* Drug related problem: Nil

7. Lab. Investigation
1- Chemical examination:
- Blood Urea *76.9 mg/dl (15-55)mg/dl
- serum creatinine *1.44mg/dl (0.6-1.4)mg/dl
- Glucose *152mg/dl (70-105) mg/dl
-Troponin T *0.155ng/ml (0.0-0.03)ng/ml
- CK-MB * 9.47ng/ml (1.35-6.73)ng/ml
Lipids profile:
- Cholesterol *280mg/dl ( less than 200 mg/dl)
- S. HDL *29mg/dl ( more than 35 mg/dl)
- T.G *210mg/dl (less than 150mg/dl)
- LDL * 209 mg/dl (less than 100)

8. 2- Hematological examination:
- Hb 13 g/dl (12.5-17.5) g/dl
- MCV 85 fl (76-100) fl
- WBC 7.64 X10^3/µl (4-11) 10^3/µl
- NEU 5.07 66.3% (2-8)
- LYM 2.07 27.1% (1-4)
- MONO 0.37 4.8% (0.2-1)
- EOS 0.12 1.6% (0.1-0.5)
- BASO 0.02 0.2% (0.0-0.2)
- PLT 349 X 10^3/µl (150-400) 10^3/µl
- ESR 16mm/hr (1 – 17) mm/hr

9. 3- Other examination:
- Chest X-ray normal.
- ECG *T inversion V2-V6.
- Echo normal Left
Ventricular Systolic
function.
- Ejection Fraction 61% (normal more
than 50%)
- Ultrasound -ve ( normal gall
bladder, spleen & liver, small renal
cyst)

10. Name of Data from data Additional data for Present
problem base problem better supporting medication
problem
- Ischemic - Coronary
Heart artery disease
disease - High blood 1- Control blood 1-clopidogrel
- Diabetic Sugar pressure. 2- bisoprolol.
- Hypertensio - 2- Control 3-atorvastatin
n Hypercholeste symptoms. 4-lisinopril
rolemia. 3- Control DM 5- aspirin.
- High blood 4- Stop smoking 6-metformin
pressure. 5- Avoid salty diet. 7-
6- Control lipid Glibenclamide
profile.

11. Current treatment (Regimen)
Name of drug Strength (Regimen) Indication Notes
- Lisinopril 10mg Tablet X1
- Bisprolol 5mg Tablet X1 Morning before
meal
- Clopidogrel 75mg Tablet X1
- Heparin 1cc (5000 IU) IV X4
-Aspirin 100mg Tablet X1 After meal
- atorvastatin *20 mg Tablet X1
- Insulin 10 units 1X3 Subcutaneousl
y ,before meal
- metformin 500mg 1X3 Orally, after
meal
O2 2-4L / min Nasal canal
nitroglycerin 0.4mg/ metered Repeated as Sublingual
dose required

12. Step no.2: Identify the Problem
*Subjective data: easy fatigue, palpitation,
epigastric pain.
*Objective data:
-Observation: looking ill, sweating.
-Vital signs: blood pressure 179/95 mmHg,
Pulse rate: 100 BPM, temperature:37c ,respiratory
rate: 14 breaths/min.
- Physical examination : well built, tachycardia,old
male .
- CNS: intact

13. Step no.3: Assessing the problem:
* We should investigated the factors cause diseases
& severity of diseases.
Factors cause IHD Hyperchole diabetes hypertens
sterolemia ion
diseases
1-diabetes √ √
2-Obesity √ √ √ √
3-Physical inactivity √ √ √ √
4-High blood pressure. √√ √
5-Smoking √√ √ √
6-Family history √√ √ √
7-Age √√ √
8-Gender √√
9-Hypercholesterolemia √√

14. Severity of diseases
* Hypercholestrolemia: uncontrolled even taken
atorvastatin 10mg/day
* DM: uncontrolled even taken metformin & Glibenclamide
* Hypertension: he’s in stage II even taken lisinopril
5mg/day.
* IHD: low severity of unstable angina.
(These are due to precipitation by smoking ,obesity
and drugs).

15. Step no.4: Devloping the plan & Therapeutic goal:
(1)- Essential Components of Therapeutic Lifestyle Changes (TLC)
Component Recommendation
LDL-raising nutrients Total fat range should be 25–35% for most cases.
Saturated fats Less than 7% of total calories.
Dietary cholesterol Less than 200 mg/day.
Therapeutic options for
LDL lowering
Plant stanols/sterols 2 g/day
Increased viscous 10–25 g/day
(soluble) fiber
Total calories Adjust caloric intake to maintain desirable body
weight and prevent weight gain
Physical activity Include enough moderate exercise
to expend at least 200 kcal/day
(2)- Control blood pressure (Less than 130/80 mm Hg)
(3)- Control blood sugar (even with combination of 2 drugs but he’s uncontrolled)

16. (4) Monitoring
Aspirin lisinopril bisoprolol clopidogrel
Efficacy - Behring -blood - BP &HR. Behring
parameter Coagulation pressure. - Glucose Coagulation
monitoring Timer (BCT) -renal function level . Timer (BCT)
- platelet test. - Lipid profile
function -monitor K- - Wt. of Pat.
analyzer level - LFT& RFT
(PFA-100)
Toxicity -epigastric - hypotension. -bradycardia - Bleeding
Parameter pain. - renal function - Hypotension - Vertigo
monitoring -peptic ulcer. impairment. - insulin - diarrhea
-GIT - change the release & - Fatigue
bleeding. taste. mask the
-Headache. - cough symptoms of
-Muscle - hypokalemia hypoglycemia.
aches. -angioedema - lipidemia
-GIT symptoms. - nightmares
- depression
- fatigue

17. atorvastatin metformin Glibenclamide
Efficacy -Fasting lipid - Random Blood - Fasting blood
parameter profile sugar or Fasting sugar .
monitoring - Liver function test blood sugar . - Random Blood
- HbA-1c test. sugar.
- HbA-1c test.
Toxicity - Muscle aches or - Lactic acidosis. - Hypoglycemia
parameter muscle weakness - gastric upset. - Increase weight.
monitoring - Increase liver - Abdominal
enzyme distension.
- headache - Nausea.
- gastrointestinal, - Headache.
constipation,
flatulence,
dyspepsia and
abdominal pain.

18. - Monitoring for Complications
Eyes Dilated eye exam yearly
Feet should be examined at every visit
Urinary microalbumin Yearly
(5)Patient Education
- Decrease salt intake.
- Regular Exercise .
- Avoid red meat.
- Take your medication regularly.
- Consult your physician if any
problem occur.

19. Therapeutic goal (Objective)
• Short Time Goal:
- Control blood pressure.
- Control blood sugar.
- Control lipid profile. (LDL) Less than 100 mg/dL ,
(HDL) Greater than 35 mg/dL,
TG Less than 150 mg/dL.
- Increase exercise tolerance near normal daily activity.
- decrease attack of ischemia .
• Long Time Goal:
- prevent complication of Ischemic diseases.
- Maintain normal daily activity.

20. Step no.5: Evaluation the achievement of
outcomes:
1. Blood pressure & blood sugar control.
2. Weight reduction.
3. Fewer physician office visit.
4. Elimination of adverse effects.
5. Maintain activity which enhanced patient
quality of life that limited by disease.
6. Cost of medication control.

21. References:
1- Patient information file from Rizgari hospital.
2- pharmaceutical care plan arrangement from
our hospital ward lectures.
3- Pharmacotherapy principles and practice,
MacGraw-Hill-medical book ,ed.2008,ch9.
4- BNF formulary57,march 2009.
5- Pharmacotherapy handbook, 7th edition, ch9.
6- American diabetes association,
http://spectrum.diabetesjournals.org/content/16/1/
41.full
7- http://srspharma,Indian manufacturing
company.