- The patient is a 60-year-old male who presented to the clinic with severe chest pain for 3 hours. Tests showed ST elevation on ECG and positive troponin levels, indicating ST elevation myocardial infarction (STEMI). - The patient has a history of hypertension and hyperlipidemia. Echo showed no blood flow to part of the myocardium. - The initial treatment plan included aspirin, clopidogrel, metoprolol, atorvastatin, lisinopril, ranitidine, morphine, and glyceryl trinitrate as needed for pain. Long-term medication and lifestyle changes were also recommended.

1. University of sulaimania
College of pharmacy
Pharmacy practice experience
II
Case SOAPing
Muhammad Kokash Sdiq
B.Sc. In pharmacy
1

2. case
• T…M is 60 year old male who is gainer and have chronic
hypertension for 10 years ago who presents to the medical clinic
at 3 a.m. With complaints for his sever chest pain for 3 hr.
Radiated to both shoulders , nausea but no vomiting , abdominal
pain , but he is conscious his blood pressure is 110/70 , troponin
test is positive , ST segment elevated in v1 ,v2 . PR= 86 bpm ,
spo2 = 96% , R.B.S= 155 mg/ dl .
• The patient has HTN and Hyperlipidemia and two days ago
undergo dental extraction . Echo show that there is no blood supply
to part of myocardium by occlusion of coronary artery .
• The ECG indicates ST segment elevation.
• Family history: his father died because of HTN and MI. His sister
also has Hyperlipidemia.
• Social history: no smoking , past- IBS . Second attack .
• Drug history: no drug allergy, on anti-hypertensive drug ( unknown)
• They agreed for thromboembolic agent just for one time .
• Diagnosis indicate ST segment elevated MI.
2

3. Subjective
• Name : T…M
• Sex : male
• Age :60
• Chief compliance : sever chest pain for 3 hr. radiated to both
shoulders , nausea but no vomiting , abdominal pain , and sever
head ache but he is conscious .
• past medical history: no drug allergy, on anti-hypertensive drug (
unkown but take diuretic for 4 month ) .
• Social history: no smoking , HTN and Hyperlipidemia. past- IBS
(now he are not taking any medication for this condition ) .
Secondary rise of BP , two days ago undergo dental extraction ).
• Family history: his father died because of HTN and MI. His sister
also has Hyperlipidemia.
3

4. Objective
• Blood pressure is 110/70 ,
• PR= 86 bpm ,
• troponin test is positive ,
• ST segment elevated in v1 ,v2 .
• spo2 = 96% ,
• R.B.S= 155 mg/ dl .
• Echocardiography show that there is no blood supply to part of
myocardium by occlusion of coronary artery.
• WBC= 13000 /mm3 (4500-11000) .
• LDL = 140 mg/dl ( 62-130) HDL= 37 mg/dl ( 35-135)
• TG = 210 mg/dl ( 0-200)
• After initial treatment :
• glucose PAP = 128 mg/dl ( 74-106).
• Urea = 62mg/dl ( 13-43 ) .
• creatinine = 0.8 mg/dl ( 0.8 – 1.3)
4

5. Assessment
• Sudden sever chest pain radiated to the shoulder
with nausea and troponin test positive and ST
segment elevation is diagnosis of ST segment
elevated MI. high level of WBC may indicate
necrosis .
• Resulted from either :
• non-compliance to antihypertensive drug .
• does not take medication for his hyperlipidemia .
• dose not control his salt and fat intake .
5

6. Planning
• Initial medication for emergency care :
• Put Cannula for patient
• Aspirin tablet 300 mg 1X1 in first day than maintained
on tablet 100 mg 1X1for two day .
• Plavix ( clopidogrel) tablet 300mg 1X1 in first time
than maintained on tablet 75 mg 1X1 for two day ..
• Motalase vial 1X1 just for one time .
• Metoprolol tablet 50 mg 1X2for two day . .
• Atorvastatin tablet 80 mg 1X1 for two day ...
• Lisinopril tablet 5 mg 1X1 for two day ..
• Zantac ( ranitidine ) tablet 150 mg 1X2 for two day ..
6

7. Planning . continue
On need medication :
• Morphine ampule 2.5 mg 1X1 at time of
attack .
• Plasil ampule 1X1 for vomiting .
• Angesid( glyceryl trinitrate ) tablet 1X1 at time
of chest pain .
7

8. Planning . continue
Recommendation :
• Patient should continue on his initial
medication until weeks and monitor .
• Motalase should not given more than
once .
• Taking of zantac tab 150mg 1x2 for qday.
8

9. Aspirin dose should be monitord
because of:
Significant intraction - Monitor Closely :
• aspirin decreases effects of metoprolol by
pharmacodynamic antagonism.
• aspirin, clopidogrel. Either increases toxicity of the other by
pharmacodynamic synergism.
• lisinopril, aspirin. Either increases toxicity of the other by
Other. May result in renal function deterioration,
particularly in elderly or volume depleted individuals.
• aspirin decreases effects of lisinopril by pharmacodynamic
antagonism. NSAIDs decrease synthesis of vasodilating
renal prostaglandins, and thus affect fluid homeostasis and
may diminish antihypertensive effect.
• metoprolol and aspirin both increase serum potassium.
9

10. Follow up
• In 24 hours to assess drug therapy changes and record outcomes.
• Arrange for follow-up within 2 weeks of discharge. Arrange for cardiac
rehabilitation.
• Good controlling of coagulation state by regular taking of aspirin 75mg 1x1 and
clopidogrel 75mg 1x1 but if clopidogrel used along is better to prevent drug
intraction of aspirin or clopidogril used if patient not tolerate aspirin , according
to regular test for 6 month by PT , PTT , BT , CT .
• Good control of HTN by lisinopril 5 mg 1x1 for 6 weeks and/or metoprolol 50mg
1x2 for 5 weeks then monitoring and follow up required .
• Good control of lipid profile by atorvastatin 10-20 mg 1x1 for years and monitor .
• Monitor renal and liver function because many drug excretd through urine .
• Regular follow up of ECG .
• Good monitoring of Vital signs .
• Good adherence to medication to prevent recurrent attack and complication .
• Take zantac for reducing risk of GI bleeding through out the course of
antiplatelet drugs .
10

11. Follow up continue
• Change in life style and diet intake
• Initially, (NPO)
• Following the patient’s initial therapy and
admission, A low-salt, low-fat, and low-
cholesterol diet is generally recommended.
• Confine patients to bed rest
• Call on call with doctor .
11

12. Thank you
12

13. • Statins:
In addition to cholesterol- lowering properties, statin has antithrombatic &
antiproliferative properties.
• ACE-Inhibitors :
Useful in patients with signs of heart failure, tachycardia or a history of
previous infarction. It should be started with 24 hrs. of diagnosis. Initial doses
should be low then titrated as quickly as the patient tolerated.
• Zantac :
To prevent stress ulceration .
• Morphine ; ( Narcotic analgesic):
It is important because pain & anxiety associated with MI will contribute to
increase myocardial O2 demand . There is no benefit in leaving a patient in
pain while the diagnosis is considered . Morphine as a pain killer ,should
administrated rapidly with an antiemetic drug such as plasil .
• Angesid : Nitrates
These agents may help to relieve pain , especially if coronary spasm produce
the MI. This is because the pain of MI can trigger the release of
catecholamine which can produce a coronary spasm.
13

14. Drug information and monitoring
• Antiplatelat
Low doses are as effective as higher doses & have a lower risk of GI
hemorrhage .
Advice the patient to take it with food .C/I in bronchospasm &a history of GI
bleeding.
Clopidogrel: Useful as an alternative to aspirin in patients who are allergic or
cannot tolerate aspirin .
• Thrombolytic agents :
It is indicated for suspected MI with chest pain of less than 6 hrs. Also for
patient with ST-segment elevation unrespond to NG .
• Metoprolol
use to reduce mortality in patient with MI to prevent recurrent MI and
complication . Is selective b-blocker, consider that its block-ing properties
(usually at higher doses) may contribute to SOB due to bronchoconstriction,
negative inotropic effects, or both.
14

15. According to Guide line ACC /AHA
• The long-term use of aspirin results in significant reduction in subsequent
mortality rate. The prescription of 75-162 mg/d of aspirin indefinitely is a
class I recommendation for patients with STEMI.
• Beta-blocker therapy has confirmed therapeutic benefit in survivors of
acute myocardial infarction.
• The use of ACE inhibitors in patients with known coronary artery disease
has been shown to reduce mortality rate.
• patients should achieve a low-density a lipoprotein (LDL) level of less than
100 mg/dL, a high-density lipoprotein (HDL) level of greater than 40
mg/dL, and a triglyceride level of less than 200 mg/dL.
• Atorvastatin significantly reduced the frequency of the combined end
point of death, recurrent death, myocardial infarction, or worsening
unstable angina requiring hospitalization.
• Clopidogrel should be prescribed for a year following discharge if the
patient has no contraindications and cost is not prohibitive. To reduce the
risk of bleeding, the aspirin dose can be reduced to 75 mg.
15