angina.docx

7/24/2019 angina.docx

1/13

CLINICAL PHARMACY CLERKSHIP

4 THYEAR BACHELOR OF PHARMACY (HONOURS)

Faculty of Pharmacy

Universiti Kebangsaan Malaysia

Clerkship Specialisation: Pharmacotherap !" I"ter"a# Me$!c!"e I

(Car$!o%a&c'#ar Re&p!rator)

Date : 2n! "thMay 2#$2

Case summary:

Unstable angina% atrial fibrillation

&ame:

Khairul Fari'a (inti Khairuin )$22*+$

PPUKM Preceptor : Miss Kong Sue ,ong

FFar Preceptor : Dr- .nang Kumolosasi

Marks:///////// 0$#


2/13

PATIENTS INFORMATION

Name: NCK Age: 77 Gender: Female

R/N: N256391 BW: 60 kg Race: Chne!e

"a#e $% adm!!$n: 29/0&/2012 '#: 155 cm B(): 25

MEDICAL HISTORIES

C/C: *re!en#ed +#h le%# !ded che!# ,an

,receded +#h ,al,#a#$n

'*): '-,er#en!$n %$r #he ,a!# 20 -ear!.

,ar$-!mal a#ral %rlla#$n $n ,re$!

adm!!$n 22/&/124

F':

Nl

':

N$n!m$ker

N$nalc$h$lc

PAST MEDICATION

HISTORY

PAST SURGICAL

HISTORY

PAST MEDICAL HISTORY

1 8 a!#arel (R 35mg B" C$r$nar- Ang$gram

CR4 n 2009

1'-,er#en!$n %$r 20 -ear!

2 /; G8N *RN 2"-!l,dema

3 8 B!$,r$l$l 75mg " 3*ar$-!mal a#ral %rlla#$n

& 8 C$er!-l *l! 1/1 "

5 8 A!,rn 75mg "

6 8 )!$rdl 10mg 8"

7 8 ;$!ec 20mg "

nder!#and (ala-/Chne!e

en!e! 'earng: Ade?a#e!$n: Ade?a#e

Wh$ l$$k! a%#er #he #rea#men# Care ger

LABORATORY INVESTIGATIONS

*arame#er/"a#e 29/& 30/& 1/5 2/5

B* mm'g4 121/50 12&/56 107/53 122/55


3/13

'R /mn4 6& 56 53 60

RR c/mn4 22 2& 2&

8em, $C4 372 37& 36&

Impression T!e !e"r# r"#e o$ #!is p"#ien# is s%i!#%' %o(er mi!# )e *"+se, )' #!e

Bisopro%o%-

=nd$crne

FB 52

'A1c @654 56

Impression T!e )%oo, %+*ose %e.e% o$ #!is p"#ien# is norm"%-

FBC

WBC &11109/;4 63 56

RBC 3


4/13

Impression T!e ren"% pro$i%e o$ #!is p"#ien# s!o(e, norm"% res+%#s-

C$agla#$n ,r$%le

)NR 21& 2&1 215

A*88 23&0 !ec!4 513 5&2

*8 1116 !ec!4 226 2&7CK 65 71 76

8r$, 8 @0013 @0013 0016

Impression T!e )%oo, *o"+%"#ion pro$i%e o$ #!is p"#ien# is !i!er #!"n #!e norm"%

%e.e%1#ime )e*"+se o$ #!e me,i*"#ions #"2en #!"# *"n *"+se )%oo,3#!innin e$$e*# s+*!

"s C%opi,ore%/ Fon,"p"rin+4 "n, Aspirin-

;,d ,r$%le

8 Ch$l @57 mm$l/;4 500

;"; @3< mm$l/;4 30&

'"; D12 mm$l/;4 1308G @1& mm$l/;4 1&7

Impression T!e #ri%'*eri,es %e.e% o$ #!is p"#ien# is !i!er #!"n #!e norm"% %e.e% "n,

is *+rren#%' *on#ro%%e, (i#! #!e Lo."s#"#in- T!e LDL %e.e% is !i! )e*"+se #!e

#"re#e, LDL $or "nin" p"#ien# is )e%o( 5-6 mmo%1L-

No

-

Me,i*"#ion N"me Reimen D"#e s#"r# In,i*"#ion

1

"g$n 05mg/2ml nE

;an$n4 025mg n 100cc

$er 30 mn#e!

!#a# d$!e4

2/5 8rea#men# $% a#ral

%rlla#$n

2

B!$,r$l$l Fmara#e 25mg

#a C$nc$r4 125mg " 2/5 8rea#men# $%

h-,er#en!$n

3

Cl$,d$grel 75mg #a

*la4 75mg " 1/5 Redce! ra#e $%

a#her$#hr$m$#c een#!

n ,a#en#! +#h n!#ale

angna

&

Ace#-l!alc-lc acd !$lle

300mg A!,rnG4 150mg " 30/& An#c$aglan# agen#

5

F$nda,arn !$dm

25mg/05ml ,re%lled !-rnge

Ar#ra4

25mg " 30/& *reen#$n $%

c$m,lca#$n! $%

n!#ale angna


5/13

6

;$a!#a#n &0mg #a

&0mg N 29/& 8rea#men# $%

d-!l,dema

7

me,ra$le 20mg ca,

;$!ecG4 20mg " 30/& *r$,h-la! $% !#re!!

ndced lcer

n!#ale angna

CURRENT MEDICATIONS

N$

(edca#$n Name

Regmen

R$#e "a#e

29/& 30/& 1/5 2/5 3/5

1 "g$n 05mg/2ml nE

;an$n4

) 1

2 B!$,r$l$l Fmara#e 25mg

#a C$nc$r4

ral 1

7s#"#8

3 Cl$,d$grel 75mg #a*la4

ral 1 1

& Ace#-l!alc-lc acd !$lle

300mg A!,rnG4

ral 1 1 1

5 F$nda,arn !$dm

25mg/05ml ,re%lled

!-rnge Ar#ra4

) 1

7s#"#8

1 1 1


6/13

6 ;$a!#a#n &0mg #a ral 1 1 1

7 me,ra$le 20mg ca,

;$!ecG4

ral 1 1 1

< )!$!$rde dn#ra#e #a

10mg )!$rdl4

ral 1 1

9 *ernd$,rl &mg

)nda,amde 125mg #a

C$er!-l *l!4

ral 1 1

10 Gl-cer-l #rn#ra#e 05mg

#a G8N4

/; 1

11 War%arn !$dm 2mg #a ral

12 8rme#adne (R 35mg

#a a!#arel (R4

ral 1 1 1

SUMMARY OF PROGRESS

"a#e Eec#e Eec#e A!!e!!men# *lan

29/& >nderl-ng '*8.

d-!l,dema. mld #$m$dera#e n$n

$!#rc#e CA". n$

c$lla,!ng ,l!e. a,eea# n$n d!,laced. n$

,edal edema

B* : n!#ale angna

=CG !h$+!rad-carda.

en#rclar

ec#$,c

#ar# F$nda,arn

25mgc$n# 8 a!#arel

(R 35mg d

c$n# /; G8N ,rnc$n# 8 B!$,r$l$l

75mg $d

c$n# 8 *ernd$,rl&mg )nda,amde

125 mg

c$n# 8 )!$!$r#e

"n#ra#e 10mg #d!c$n# 8 me,ra$le

20mg $d

c$n# 8 ;$a!#a#n&0mg $n

8 War%arn 2mg $d

=CG !#ar# % che!#,an

30/& >nderl-ng '*8.

d-!l,dema. mld #$

m$dera#e n$n

$!#rc#e CA". n$c$lla,!ng ,l!e. a,e

ea# n$n d!,laced. n$

,edal edema

B* : 100/57

*R : 5&

8 : 37

RR:20

>n!#ale angna C$n# F$nda,arn

and $#her medca#$n

+#h$ld B!$,r$l$l

=CG !#ar# % che!#,an

re%er card$ %$r

ang$gram


7/13

1/5

Che!# ,an.n$ !$. ,an

a# cen#ral $% che!#.c$nc$!. aler#

B*: 1&6/n!#ale angna ! charac#er!ed - an malance e#+een m-$cardal $-gen !,,l- and

demand 8he m$!# c$mm$n ca!e $% >A ! redced m-$cardal ,er%!$n #ha# re!l#! %r$m

c$r$nar- ar#er- narr$+ng ca!ed - a #hr$m! #ha# deel$,ed $n a d!r,#ed

a#her$!cler$#c ,la?e and ! !all- n$n$ccl!e (cr$em$l!a#$n $% ,la#ele# aggrega#e!

and c$m,$nen#! $% #he d!r,#ed ,la?e ca!ng d!#al mcr$n%arc#$n ! eleed #$ e

re!,$n!le %$r #he relea!e $% m-$cardal marker! n man- $% #he!e ,a#en#!

A le!! c$mm$n ca!e ! d-namc $!#rc#$n. +hch ma- e ca!ed - n#en!e %$cal

!,a!m $% a !egmen# $% an e,cardal c$r$nar- ar#er- *rnme#al! angna4 8h! !,a!m !

ca!ed - h-,erc$n#rac#l#- $% a!clar !m$$#h m!cle and/$r - end$#helal d-!%nc#$n

"-namc c$r$nar- $!#rc#$n can al!$ e ca!ed - #he an$rmal c$n!#rc#$n $% !maller

e!!el!

A #hrd ca!e $% >A ! !eere narr$+ng +#h$# !,a!m $r #hr$m! 8h! $ccr! n !$me

,a#en#! +#h ,r$gre!!e a#her$!cler$!! $r +#h re!#en$!! a%#er a ,erc#ane$! c$r$nar-

n#eren#$n *C)4

8he %$r#h ca!e ! ar#eral n%lamma#$n. ca!ed - $r rela#ed #$ n%ec#$n. +hch ma- e

re!,$n!le %$r ar#eral narr$+ng. ,la?e de!#al!a#$n. r,#re and #hr$m$gene!!

Ac#a#ed macr$,hage! and 8l-m,h$c-#e! l$ca#ed a# #he !h$lder $% a ,la?e ncrea!e #he

e,re!!$n $% en-me! !ch a! me#all$,r$#ena!e! #ha# ma- ca!e #hnnng and d!r,#$n $%

#he ,la?e. +hch n #rn ma- lead #$ >A


8/13

8he %%#h ca!e ! >A !ec$ndar- #$ a ,rec,#a#ng c$nd#$n. +hch ! e#rn!c #$ #he

c$r$nar- ar#eral ed 8he!e ,a#en#! hae nderl-ng c$r$nar- a#her$!cler$#c narr$+ng #ha#

lm#! m-$cardal ,er%!$n. and #he- $%#en hae chr$nc !#ale angna>A !ec$ndar- #$

,rec,#a#ng c$nd#$n! nclde!:

)ncrea!ed m-$cardal $-gen re?remen#!. !ch a! %eer.#ach-carda and #h-r$#$c$!!

Redced c$r$nar- l$$d %l$+ !ch a! h-,$#en!$n

Redced m-$cardal $-gen deler-. !ch a! anaema $r h-,$aema

)- Tre"#men# o"%

1 8$ mmeda#e rele% $% che!# ,an de #$ angna a##ack H #h! eca!e !$me#me! #he

,a#en# che!# ,an d$ n$# re!$le a%#er #akng !ngle d$!e $% /; G8N and need e#ra d$!e

#$ re!$le

2 8$ ,reen# #he recrrence $% angna a##ackH #he ,a#en# ha! AF and ma- ca!e hear# %alre

and ()

3 *reen#$n $% !#r$ke and #ach-cardandced card$m-$,a#h- and amel$ra#$n $%!-m,#$m!H #h! eca!e #he ,a#en# hae AF and ma- ca!e !#r$ke and $#her !-m,#$m!

#ha# ,re!en# n #he ,a#en# !ch a! ,al,#a#$n. che!# d!c$m%$r#. and !h$r#ne!! $% rea#h

c Ac#al and rec$mmended #rea#men#

Acc$rdng #$ Clncal *rac#ce Gdelne! $n >A/N8=() 2011. #he g$al $%

managemen# are #$ mmeda#e rele% $% $ng$ng !chema and angna. ,reen#$n $% recrren#

!chema. angna and !er$! ader!e cardac een# 8he %r!# rec$mmended medca#$n !

$ral an#,la#ele# agen# !ch a! ace#-l!alc-clc acd +hch ! aldread- gen n #h! ,a#en#

Ne# ! Aden$!ne ",h$!,ha#e Rece,#$r Ag$n!# !ch a! cl$,d$grel and #cl$d,ne )n #h!

,a#en# cl$,dr$grel 75mg $d ! gen and ! a,,r$,ra#e An#c$aglan# al!$ ! rec$mmended

n #he gdelne and n #h! ,a#en#. %$nda,arn 25mg ! gen and ! a,,r$,ra#e Ne#

rec$mmenda#$n ! an#!chemc drg #here,- +hch nclde n#ra#e! and e#a l$cker )n

#h! ,a#en#. /; G8N and !$!$rde dn#ra#e ! gen +hle !$,r$l$l +a! +#h$ld n #h!

,a#en# de #$ l$+ hear# ra#e #ha# ma- e de #$ e%%ec# $% !$,r$l$l nce #h! ,a#en# n$#

!#ale %$r #akng e#a l$cker. calcm channel l$cker !ch a! era,aml $r dl#aam can

e gen a! an al#erna#e Ne# ! l,d m$d%-ng drg! ! rec$mmended a! # hae een

%$nd #$ redce maE$r cardac een#! !ch a! a#$ra!#a#n and !ma!#a#n. +hle #h! ,a#en#

had recee l$a!#a#n ;a!#l- #he rec$mmended medca#$n ! AC= nh#$r %$r l$ng #erm,reen#$n $% recrren# !chema and #h! ,a#en# ha! receed ,ernd$,rl


9/13

d ($n#$rng $% #rea#men# e%%cac- and !a%e#-

"rg )ndca#$n! ($n#$r e%%cac- ($n#$r !a%e#-

F$nda,arn !$dm

25mg/05ml ,re%lled

!-rnge A#r#ra4". !c

($n#$r CBC.

,la#ele# c$n#. !#$$l

$ccl# l$$d #e!#. !gnand !-m,#$m! $%

ner$l$gcal

m,armen#

C$n#r$lled $% l$$d

,re!!re #$ de!red

#arge# 130/


10/13

m-$!n lgh# chan!.

,reen#ng n#erac#$n$% m-$!n and ac#n.

ca!e !m$$#h m!cle

relaa#$n

m$#h $r lrred

!$n deel$,ed

;$a!#a#n &0mgn

8rea#men# %$rh-,erch$le!#er$lema

Ac# - c$m,e##el-

nh#ng '(GC$A

redc#a!e #he en-me#ha# ca#al-!e #he ra#e

lm#ng !#e, n

ch$le!#er$l$!-n#he!!

;,d ,r$%lem$n#$rng +#h#arge# ;"; acheed

#an l,d ,r$%le

%$r re!,$n!e a# &

+eek!

($n#$r ler%nc#$n #e!# e%$ren#a#ng #hera,-. a# 6

and 12 +eek! a%#er

n#a#$n $% #hera,-

$r elea#$n $% d$!e.and 6 m$n#h!

#herea%#er n ,a#en#

+#h h!#$r- $%he,a#c m,armen# $%

,a#en# clncall-

ndca#ed A!!e!!crea#nne kna!e

leel! +hen

!-m,#$ma#cm-$,a#h- $ccr!

(a- c$n!der

m$n#$rng crea#nne

kna!e leel! #$,a#en# n#a#ng

l$a!#a#n #hera,- $r

+hen d$!e ncrea!ed

8em,$rar-d!c$n#ne #rea#men#

% m-$,a#h-!!,ec#ed $r !erm

#ran!mna!e leel!

eceed 3 #me!

n$rmal leel

G8N 05mg Ac#e #rea#men# $%

angna N#ra#e! !#aken , - a!clar

!m$$#h m!cle.

me#a$led #$ n#rc$de. !#mla#e

gan-la#e c-cla!e.

c$ner# G8* #$cG(*. ncrea!e

cG(* ac#a#e

,r$#en kna!e G.

de,h$!,h$r-la!e

Relee $% che!# ,an.

hear# ra#e and l$$d,re!!re

($n#$r %$r !de

e%%ec# $% G8N:headache. ,$!#ral

h-,$#en!$n. re%le

#arch-carda'$+eer #he !de

e%%ec# ! le!!er

eca!e e#a l$cker! gen


11/13

m-$!n lgh# chan!.

,reen#ng n#erac#$n$% m-$!n and ac#n.

ca!e !m$$#h m!cle

relaa#$n

8 8rme#adne (Ra!#eral (R4 35mgd

*r$,h-lac#c#rea#men# $% e,!$de!$% angna ,ec#$r!

AdEan#

!-m,#$ma#c

#rea#men# $% er#g$and #nn#!

AdEan# #rea#men# $%

#he declne n !alac#- and !al

%eld d!#rance!

,re!mal- $%a!clar $rgn

8 !egmen# $%de,re!!$n. ncden#$% angna a##ack

($n#$r !de e%%ec# $%8(I :Ga!#r$n#e!#nal

d!$rder!.headache!.

er#g$. !lee,

d!$rder!.aggraa#$n $%

*arkn!$nan

!-m,#$m!.r#h$!#a#c

h-,$#en!$n +hch

ma- c$n#r#e #$er#g$. %an#ng and

%allng n elderl-

8 B!$,r$l$l

Fmara#e75mg $d

*reen#$n $%

recrren# !chemc

hear# d!ea!e

!-m,#$m!

B*. 'ear# ra#e and

=CG

Bl$$d ,re!!re. =CG

($n#$r ,a#en# B*

!nce ,a#en# hae

l$+ B*

*ernd$,rl =rmne

&mg and )nda,amde125mg

8rea#men# $%

h-,er#en!$n

Bl$$d ,re!!re B*. B>N. !erm

crea#ne andelec#r$l-#e!

"g$n 8rea#men# $% a#ral

%rlla#$n

erm dg$n leel.

hear# ra#e. =CG

erm ,$#a!!m

leel. erm dg$nleel. hear# ra#e. =CG


12/13

PHARMACEUTICAL CARE ISSUES

N$ "e!cr,#$n $%!!e

C$m,lca#$n $% !!e (anagemen# $% !!e ($n#$rng $% !!e

1 *anmanagemen#

*a#en# !%%er! %r$mche!# ,an de #$

angna a##ack

Ge $,$d %$r mld#$m$dera#e ,an !ch

a! #ramad$l $r

dh-dr$c$dene

($n#$r #he ,an !c$re$% ,a#en#

($n#$r #he !de

e%%ec#! $% $,$d drg.

eg re!,ra#$r-de,re!!$n

2 "rgn#erac#$n

*$#en#al4

8he !-nerg!#c e%%ec#e#+een A!,rn.

F$nda,arn and

Cl$,d$grel ma-ncrea!e #he r!k $%

leedng

#$, F$nda,arna%#er #he c$m,le#$n

$% regmen

($n#$r ,a#en#!l$$d c$agla#$n

,r$%le

($n#$r #he ,re!ence$% leedng !$ #ha#

a,,r$,ra#e #rea#men#

can e gen a! !$$n a!

,$!!le

3 "rg

admn!#ra#$n#echn?e

8he !lngal G8N

ma- n$# eadmn!#ered c$rrec#l-

eca!e #he angna

a##ack ! n$# re!$leda%#er 3 #ale#!

=dca#e #he ,a#en#

$n #he rgh# +a- $%!lngal

admn!#ra#$n

Change #he!lngal #ale# #$

N#r$lngal ,m,!,ra-

($n#$r #he dra#$n

$% angna a##ack($n#$r #he

admn!#ra#$n

#echn?e

REFERENCES

1 ()( (ala-!a

2 ;ac-. CF. Arm!#r$ng. ;; e# al 20102011 ;eC$m,! "rg )n%$rma#$n 'and$$k

19#h=d#$n

3 W' *an (anagemen# ;adder

& Clncal *rac#ce Gdelne! $n #he (anagemen# $% >A and N8=(). Jne 20115 Clncal *rac#ce Gdelne! $n #he (anagemen# $% '-,er#en!$n. Ferar- 200


13/13

9. *a##er!$n. "; 19

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