Case No.

:
Date:

SUBJECTIVE
PROBLEM

OBJECTIVE

ASSESSMEN
T

PLAN

1.VITAL SIGNS

ETIOLOGY OF

1.EVALUATE

GOALS FOR

RECOMMEND

2.LAB TESTS

PROBLEM

CURRENT

TREATMEN

1. DRUG TREATMENT FOR

THERAPY FOR

T OF

PROBLEM

PROBLEM

PROBLEM

2. MONITORING PARAMETERS

3.MED.LIST

2.EVALUATE

FOR EACH DRUG LISTED

NEED FOR

3. FURTHER TESTS FOR

THERAPY

PROBLEM IF NEEDED

PATIENT
EDUCATIO

4. DRUGS TO BE AVOIDED AND

coronary artery disease

VITALS:

A female patient of 83yrs was

PR: 66/min

admitted on 28/07/2014 with

B.P: 180/90 mm of Hg

c/o chest pain-2days, radiating

CVS : s1 s2 + +

to neck, back and arm.

RS: Clear

PMH: known case of Diabetes

ABD: Soft

mellitus and Hypertension

Labs:

since 2 yrs.

DATE
EOSINOPHILS
BLOOD SUGAR
(F)
HDL
cholesterol
VLDL
cholesterol

1
01%
79mgs/dl
29mgs/dl
18.8mgd/dl

Current medication:
Tab.nitro glycerine stat
Inj.pantoprazole 40mg OD
Inj.ceftrioxone 1gm OD
Tab.amlodipine 5mg OD
Tab.glyciphage 500mg BD
Tab.ecospirin 75mg OD
Tab.clopidogrel 75mg OD

CAD is due to
sub intimal
deposition of
atheromas in
small and
medium-sized
coronary
arteries

WHY
1.Tab.nitro glycerine stat

1. the current

1.Prevent the

therapy for the

platelet

Inj.pantoprazole 40mg OD

medication adher

problem to

aggregation.

Inj.ceftrioxone 1gm OD

Strengthening the

reduce fat

And reduce

Tab.amlodipine 5mg OD

and hand muscles

Tab.glyciphage 500mg BD

balance through r

Tab.ecospirin 75mg OD

walking and exerc

Tab.clopidogrel 75mg OD

2. maintain norma

Tab.atorvastatin 40mg HS

3. controlled cond

accumulation in
blood vessels and
decrease the
blood volume to

atheroma
formation and
there by
reduce the
chest pain.

1. Continue emph

reduce the work

2. blood pressure should moniter

of hypertension a

load of the heart

while

diabetes.

Need for

glycerine,

4.. reduce and ma

Therapy:

3.ECG and ECHO Cardiogram is

stress

therapy is

recommended.

administering nitro

required. To
reduce the chest
pain due to
occlusion of
atheroma in
coronary artery
Continue current
therapy to

Department of Pharmacy Practice, Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor-517127 (AP), INDIA

Case No.:
Date:

Tab.atorvastatin 40mg HS

prevent further

Inj.furosemide 20mg SOS

TIA and CVA.

Tab.cefadroxil 75mg BD
Inj.actrapid SOS

Department of Pharmacy Practice, Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor-517127 (AP), INDIA