CASE PRESENTATION ON DYSLIPIDEMIA PRESENTED BY TUSHAR 170518882026 SUBJECTIVE EVIDENCE • Chief compliant :CHEST DISCOMFORT • Past medical history : HYEPRTENSION Type-2 DIABETES MILLETUS, KCO • Past medication history : Tab ECOSPORIN,Atrovas • Allergies : NKDA OBJECTIVE EVIDENCE • General appearance : Height = 158 cm Weight = 78 kg BMI = 31.3 kg/m² ( Normal ) • Vitals : Temp - 98° F Heart rate – 86 bpm B.P – 110/80 mmHg Respiratory rate – 20 breaths/min Blood sugar- 98 LAB INVESTIGATION TEST RESULT NORMAL Hb 13.2g/dl 11-16g/dl TLC 73,000cells/mm³ 4000-11000cells/mm³ PLATELET COUNT 313,000 150000-400000 SERUM CREATININE 0.78 0.6-1.4mg/dl BLOOD UREA 22 14-45 mg/dl SERUM SODIUM 139 135-155mol/L SERUM POTASSIUM 4.4 3.6-5.5 mol/L SERUM CHLORIDES 102 98-108 mol/L Pharmaceutical care plan SUBJECTIVE EVIDENCE CHEST PAIN, SWEATING AND PALPITATIONS OBJECTIVE EVIDENCE VITALS ARE STABLE FINAL DIAGNOSIS • CHEST PAIN, CORONARY ARTERY DISEASE • DYSLIPIDEMIA OTHER INVESTIGATIONS CORONARY ANGIGRAM OPTICAL COHERENCE TOMOGRAPHY ECG SINUS RHYTYM Q WAVE ST ELEVATION Increases High sensitivity troponin in plasma ASSESSMENT Day 1 : VITALS ARE STABLE NO FEVER Ecospirin given dose 150 gm Atrovastatin tab given 20mg Atenolol(50g) and losartan(50g) given for increased blood pressure DAY 2: Vitals stable Dolo 650mg dose given Day 3: •Cardace 2.5mg given •Aceclofenac tablets anti imflammatory drug administered for pain • • • • Day 4 : Vitals stable No new issues Same therapy followed DAY 5: Vitals stable DRUG CHART BRAND NAME GENERIC NAME DOSE ROUTE FREQUENCY Ecospirin tab aspirin 1.5 gm PO BD Atrovas tab atrovastatin 75 g in 1000m/ml PO BD Met xl tab methotrexat e 10 mg PO BD Tab PAN pantroprazol 60 ml e PO OD Tab nitrocontin Glycerytlic nitrate 60ml PO OD Tab brillinta ticagrelor 1 tablet PO TID USES BRAND NAME GENERIC NAME DOSE ROUTE FREQUENCY USES Tab rozavel rosurvastati n 20mg PO OD prolomet tab metaprolol 50mg PO OD pantocid tab pantoprazol e 25mg PO OD IV fluid ns Normal saline 50mg IV OD Cardace tab ramipril 1 tab PO BD Dolo tab acetaminop hen 650 mg PO BD PLAN LIFESTYLE MODIFICATIONS • involves dietary advice and aerobic exercise • to control the body weight • LOW fat diet for dyslipidemic patients PREVENTION • Maintain balance diet. • Engage in regular exercise. • Eat foods that are good for health, such as fruits and vegetables. • Avoid smoking and limit alcohol to 2-3 drinks per day. DISCHARGE MEDICATIONS BRAND NAME GENERIC NAME DOS E ROUT FREQ E Tab ecospirin aspirin 1 tab PO OD Anti imflammat ory drug Tab prolomet metaprolol I tab OD Beta blocker Po INDICATIO N
