Question

Mr FG is a 69-year-old retired school teacher who was admitted to the emergencydepartment complaining of severe chest pain after climbing stairs at hisdaughter’s house. In the ambulance he is administered aspirin 300 mg. Onarrival at hospital and subsequent examination and review by the admittingdoctor the following information is obtained.

Previous medical history

Hypertension (10 years). Type 2 diabetes mellitus (recently diagnosed, currentlydiet controlled). The patient is a regular cigarette smoker (>40 per day) anddrinks approximately 10 units of alcohol per week. He has osteoarthritis of theknee.

Family history

Father died following a myocardial infarction at 60 years of age. No maternal

history of cardiovascular disease.

Drug history

Allergies: Trimethoprim. Mr FG has been taking diclofenac MR tablets 75 mg

(twice daily) and nifedipine (Adalat Retard) MR tablets 20 mg (twice daily). Both

were stopped on admission.

Signs and symptoms on examination

▪ Temperature 36.4°C

▪ Blood pressure 160/80 mmHg

▪ Heart rate 75 b/m, regular

▪ Respiratory rate 15 breaths per minute

▪ No basal crackles in the lungs.

▪ An ECG taken immediately on arrival reveals ST elevation of 3 mm in the inferior

▪ leads.

Diagnosis

A preliminary diagnosis of myocardial infarction is made.

Relevant test results

Full blood counts, liver function tests, electrolytes and renal function, CXR,total cholesterol, full blood count and blood glucose were taken at admission.

The following tests taken at admission are reported:

Na+ 134 mmol/L (135–145 mmol/L)

K+ 4.3 mmol/L (3.5–4.0 mmol/L)

Urea 5.2 mmol/L (0–7.5 mmol/L)

Creatinine 81 micromol/L (35–125 micromol/L)

Total cholesterol 5.9 mmol/L (<4 mmol/L)

Blood glucose 4.4 mmol/L (4–10 mmol/L)

Initial treatment

About 45 minutes after the onset of chest pain the patient received the following

treatment in the emergency department:

▪ Heparin 5000 units stat

▪ Reteplase 10 units i.v. bolus followed by a further 10 unit i.v. bolus after 30minutes

▪ Diamorphine 2.5 mg IV stat

▪ Metoclopramide 10 mg stat.

▪ A sliding scale insulin infusion of Actrapid 50 units made up to 50 mL with

sodium chloride 0.9% was initiated and titrated against blood glucose.

The patient is subsequently transferred 2 hours later to the coronary care unit as he is pain-free. As the ward cli

nical pharmacist, you are responsible for dailyreview of drug charts and advice to medical and nursing staff on all aspects ofdrug treatment for patients on the ward.

7. What advice should be given to the patient at discharge with regard to lifestyle

issues?

Answer 1

The above patient is diagnosed with myocardial infarction, it is the condition characterized by death of the myocardial cell due to lack of oxygen or tissue perfusion.most common cause is the occlusion of coronary artery due to atheromatic plaque formation .

The risk factors for this atherosclerosis include modifiable and non modifiable risk factors .

Modifiable risk factors especially life style factors such as alcoholism, smoking, sedentary life style, hyperlipidemia etc.

Discharge advices

:first of all educate them about ill effects of alcoholism and advice to avoid alcoholism

:educate to stop smoking

:educate them about dietary modification, include more fruits and vegetables in diet, avoid trans fat and take low fat diet. Try to avoid grape fruits it may interfere the action of antilipidemic agents.

:do minimum exercise as advices by the physician .

:avoid strainous activities it may increase cardiac work load and may cause further worsening of condition.

:report to hospital for any unusual symptoms noted such as chest pain, sweating ,bleeding etc,

:advice to take salt restricted diet to contol hypertension .

:avoid stressful situation as possible .