Phar 313: Clinical Pharmacy

CASE 1
 Demographics
• Name: N.S.F.
• Date of admission: October 11, 2013
• Resident-in-charge: Dr. R. Querol
• Age/Sex: 55/ male
 History of Present Illness
• In 2011, patient was admitted for surgery
for slipped disk, however, on workup px
was diagnosed with 3 vessel CAD via
coro-angio, since then maintained on ASA,
Clopidogrel, Diltiazem, Losartan, ISMN,
Simvastatin for dyslipidemia.
 History of Present Illness
• Patient was advised CABG however did
not comply. Since then he experienced
baseline dyspnea and chest pain

• CHIEF COMPLAINT UPON ADMISSION:

chest heaviness
 Lifestyle
• ( + ) 13 pack years smoker

• ( - ) alcohol drinker

• Denies illicit drug use

 Family Medical History
• (+) Hypertension
 Review of Systems
• (-) fever
• (-) cough
• (-) orthopnea
• (-) abdominal pain
• (-) weight loss
 Physical Examination
• BP: 110/70
• HR: 70
• RR: 20
• Temp: afebrile
• HEENT: PC, AS
• Chest/lungs: ECE, CBS
• Skin: pink nailbeds
 VITAL SIGNS
10/18 10/19 10/20
N 119/71 110/80
BLOOD
D 100/80
PRESSURE
E 100/80
N 82
HEART
D
RATE
E
N 18 18
RESPIRATORY
D 18
RATE
E 18
N 36.2
TEMPERATURE D
E 36
 HEMATOLOGY
10/12 10/17 10/19 REMARKS

RBC 4-6.2 4.73 4.97 4.69

Hgb 120-180 150 150 139
HCT 0.37-0.54% 0.448 0.454 0.423
MCV 80-96 94.7 91.4 90.2
MCH 27-31 31.7 30.1 29.6
MCHC 320-360 334 329 328
WBC 4.5-11 6.25 7.71 13.06
NEUT 50-70% 50 46 76
LYMPH% 20-44% 35 36 12
MONO% 2-9% 8 10 11
EOSIN% 0-4% 6 7
BASO% 0-2% 1 1 1
PLT 150-450 211 238 153
PROTHROMBIN TIME
10/12 10/19
CONTROL (12-15 SEC) 13 13
PATIENT’S VALUE 12.9 15.9
INR 0.99 1.3

APTT 10/12 10/19

CONTROL (25-45 29.6 29.6
SEC)
PATIENT’S VALUE 30.5 37.4
 BLOOD CHEMISTRY
10/12 10/13 10/17 10/19 10/21
GLUCOSE 4.1-6.6 4.9
BUN 2.9-9.3 3.7 5.0
CREATININE 57-113 73 75 72
ALBUMIN 35-48 35
SODIUM 136-144 139
POTASSIUM 3.6-5.1 3.7 3.9 3.7
CALCIUM 2.23-2.58 2.29 2.21
MAGNESIUM 0.7-1 1.03 0.95
 OTHERS
10/12
TROPONIN I 0 – 0.12 <0.012

ECG / RADIOGRAPH
DATE: 10/12
IMPRESSION: REGULAR SINUS RHYTHM NORMAL
AXIS NON SPECIFIC ST-T WAVE CHANGES
 ECHOCARDIOGRAM
• Concentric remodelling with good wall motion &
contractility & preserved overall systolic function
• Normal sized left atrium right atrium and right
ventricle
• Aortic and pulmonic valve sclerosis
• Doppler evidence of diastolic relaxation
abnormality
• Grade 2 aortic regurgitation
• Mild tricuspid regurgitation
• Pulmonic regurgitation
• Normal pulmonary artery pressure
 PRESENT WORKING
IMPRESSION
• 3 Vessel CAD w/ HCVD
• s/p CABG (10/18) post op Pericarditis
• s/p Coronary Angiography (2011,
10/14/13)
• HPN st. 2
• Dyslipidemia
• Slipped disc
 CORONARY ARTERY DISEASE
(CAD)
• occurs when the inside (the lumen) of one or more
coronary arteries narrows, limiting the flow of oxygen-
rich blood to surrounding heart muscle tissue.

• Atherosclerosis is the process that causes the artery

wall to get thick and stiff. It can lead to complete
blockage of the artery, which can cause a heart attack.

• Traditional risk factors are high LDL, low HDL, high

BP, family history, diabetes, smoking and being over
45 yrs for men.
CORONARY ARTERY DISEASE
(CAD)
CORONARY ARTERY DISEASE
(CAD)
 HYPERTENSIVE
CARDIOVASCULAR DISEASE
(HCVD)
CORONARY ARTERY BYPASS
GRAFT SURGERY (CABG)
CORONARY ANGIOGRAPHY
HYPERTENSION
DYSLIPIDEMIA
SLIPPED DISC
 DRUG THERAPY PLAN
DRUG INDICATION COMPLIANCE
PRESCRIBED
OCT 18 OCT 19 OCT 20

Morphine 8 10 12 2 4 6 8 2 4 6 8
sulfate 1mg IV 4 6 8 10 8 10 12 2
q2h 2 2 10 12 4 6 8 10 12
 DRUG THERAPY PLAN
DRUG INDICATION COMPLIANCE
PRESCRIBED
OCT 19 OCT 20 OCT 21
Omeprazole 8 5:30
40mg tab 1 tab
OD

Aspirin 80mg 12 12
tab
1 tab OD

Isosorbide 8 8
mononitrate
30mg tab
1 tab OD at HS
Rosuvastatin 8 8 8
10mg tab
1 tab OD
 DRUG THERAPY PLAN
DRUG INDICATION COMPLIANCE
PRESCRIBED
OCT 19 OCT 20 OCT 21
Metoprolol 6 8 6 8 6
50mg tab
½ tab BID

Losartan 50mg 8 8
tab
1 tab OD
Clopidogrel 12 8
75mg tab
1 tab OD

Co-amoxiclav 8 6
1gm tab BID x 7
days
 DRUG THERAPY PLAN
DRUG INDICATION COMPLIANCE
PRESCRIBED
OCT 19 OCT 20 OCT 21

PRN DRUGS

Morphine
sulfate 1 – 2 mg
IV q6h

Mupirocin 8 4 12 8 4 12
ointment on
right scapular
area
 Omeprazole
• Proton pump inhibitor
• Suppresses gastric basal
and stimulated acid
secretion by inhibiting the
parietal cell
H+/K+ ATP pump
Morphine Sulfate
Aspirin
Isosorbide mononitrate
Rosuvastatin
Metoprolol
Losartan
Clopidogrel
Co-amoxiclav
Mupirocin ointment
Healthcare Therapeutic Monitoring Desired
Recommendation
Need Goal Parameters Endpoint Frequency
 Drug interactions
DRUGS INVOLVED INTERACTION MANAGEMENT
References