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CASE 1

Patient Database:
Demographic Data
Name: WLO Weight: - kg
Age: 69 years old Height: - cm
Gender: Female Date of admission: 18/4/2014
Race: Chinese MRN: 1915303
Ward/Bed: W24/B15

Chief Complaint
Having bilateral leg swelling, periorbital swelling and mild shortness of breath (SOB).

History of Present illness
Bilateral leg swelling
Periorbital swelling

Past Medical History
Diabetes Mellitus (DM)
Hypertension (HTN)
Ischaemic Heart Disease (IHD)
Chronic Kidney Disease (CKD)

Family history / Social history
NA.

Past Medication history
Simvastatin 40 mg, Aspirin 300 mg,
Furosemide 40 mg, Felodipine 10 mg,
Metoprolol 100 mg, Minoxidil 5 mg,
Ferrous Fumarate 200 mg, Neurobion 1 tablet,
SC Actrapid, SC Insulatard.

Allergy
No known drug allergy (NKDA).

Review of system
BP: 135/50 mmHg RR: 21 b/min
PR: 67 p/min T: 37 C
Patient denies chest pain, nausea or vomiting, abdominal pain, fever and UTI symptoms.

Compliance evaluation
NA.

Physical examination
General: alert, oriented, speak in full sentence.
Head: bilateral periorbital oedema.
Lung: decreased breath sounds bibasally.
Abdomen: soft and not tender.

Diagnosis / Surgical procedure
Decompensated CCF (Congestive Cardiac Failure) 2
o
to non-compliance to restriction of fluid
(ROF).

Admission medication chart
Drug Dosage regimen Date start Date stop
T. Simvastatin 40 mg ON 19/4/14 Ongoing
T. Aspirin 75 mg OD 19/4/14 Ongoing
T. Ferrous Fumarate 200 mg OD 19/4/14 Ongoing
T. Furosemide 40 mg OD 19/4/14 Ongoing
IV Furosemide 20 mg in between transfusion 20/4/14 20/4/14
SC Actrapid 6 units TDS 19/4/14 Ongoing
SC Insulatard 8 units ON 19/4/14 Ongoing
T. Neurobion (Vitamin B1, B6, B12) 1 tablet OD 20/4/14 Ongoing

Significant laboratory data
(a) Full blood count
Day, Date
& Time

N. Range
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
18/4
22:30
19/4
03:10
19/4
08:00
19/4
15:00
19/4
21:45
20/4
03:30

20/4
08:30

20/4
15:55

20/4
22:00

21/4
03:00

21/4
08:00


TWBC 411 x10/L 4.4
Hb 12-15
g/100mL
*8.3
RBC 3.8-4.8x10
12
/L *2.94
HCT 0.4/0.36-
0.52/0.46
*0.25
Platelet 150-400x10
9
/L *127

(b) Renal profile
Urea 1.7-8.3 mmol/L *25.2
Na 135-145 mmol/L 141
K 3.5-5.0 mmol/L 3.5
Cl 96-106 mmol/L 106
Ca 2.1-2.6 mmol/L
Mg 0.7-1.3 mmol/L
PO4- 0.8-1.45 mmol/L
SCr 64-122 umol/L 316
ClCr 105-150 Ml/min
(c) Liver profile
Albumin 35 50 g/L
38
T.Bilirubin <20 umol/L
3
T.Protein 66 87 g/L
74
ALP 53 141 u/L
76
ALT <32 u/L
20


(d) Cardiac enzyme
CK 24 195 u/l 188
LDH 0 248 u/l
AAT <37

(e) Blood glucose profile













Date 7 a.m. (Pre-breakfast) 11 a.m. (Pre-lunch) 5 p.m. (Pre-dinner) 10 p.m. (Pre-bed)
19/4/14 (mmol/L) 12.2 16.4 11.6 15.9
20/4/14 (mmol/L) 6.2 11.2 11.7 9.4
21/4/14 (mmol/L) 10.7
(f) Vital signs
BP
135/50 128/54 119/51 140/58 134/61 118/60 128/58 150/73 134/61 119/74 132/62
TEMP
37 37 37 37 37 37 37 37 37 37 37
RR 12 18 b/min
21 18 20 20 20 19 20 20 21 19 19
PR 60 100
p/min
67 64 68 79 67 62 60 65 60 71 66

(g) Lipid
Date
T. Chol < 5.7 mmol/L
C-TG < 1.7 mmol/L
C-HDL > 1.7 mmol/L
C-LDL < 3.9 mmol/L

(h) I/O chart








Date 19/4 20/4
Input 800 688
Output 700 3100
Balance +100 -2412
Blood transfusion on 20/4/14 (due to anemia)
Blood product: 16 packed cell (IV Furosemide 20 mg in between transfusion)
Time start: 8.25 pm
Time complete: 2.25 am
Allergic reactions: No
Vital sign during transfusion:
Schedule Time Pulse (p/min) Blood pressure (mmHg) Temperature (
o
C)
Baseline 8.25 pm 63 127/53 37
15 minutes 8.40 pm 64 131/50 37
30 minutes 9.10 pm 73 120/56 37
Hourly 10.10 pm 69 111/74 37
11.10 pm 63 101/75 37
12.10 am 60 121/70 37
1.10 am 64 118/84 37
2.10 am 61 105/63 37








Drug-related problems / Pharmaceutical care issues
DRP 1: Appropriateness of addition of ACE-I / ARBs in the management of hypertension with diabetes and chronic kidney disease.

S Patient is having bilateral leg swelling, periorbital swelling and mild shortness of breath (SOB).
O Past Medical History: Diabetes Mellitus, Hypertension, Ischaemic Heart Disease, Chronic Kidney Disease.
Diagnosis: Decompensated Congestive Cardiac Failure 2
o
to non-compliance to restriction of fluid (ROF).
Admission medication chart:
Drug Dosage regimen Date start Date stop
T. Furosemide 40 mg OD 19/4/14 Ongoing
IV Furosemide 20 mg in between transfusion 20/4/14 20/4/14
T. Simvastatin 40 mg ON 19/4/14 Ongoing
T. Aspirin 75 mg OD 19/4/14 Ongoing

18/4
22:30
19/4
03:10
19/4
08:00
19/4
15:00
19/4
21:45
20/4
03:30
20/4
08:30
20/4
15:55
20/4
22:00
21/4
03:00
21/4
08:00
BP
135/50 128/54 119/51 140/58 134/61 118/60 128/58 150/73 134/61 119/74 132/62
Serum creatinine on 19/4: 316 mol/La
A Congestive cardiac failure is the most common discharge diagnosis in patient > 65 years old.
1

The treatment goals for management of heart failure are:
2,3

1. To relieve or reduce symptoms of heart failure.
2. To prevent or minimize hospitalizations for exacerbations of heart failure.
3. To prolong the survival of patient and reduce morbidity rates within the population of patients with heart failure.
4. To improve patients quality of life.
Factors contributing to decompensated CCF: excessive fluid and salt intake, anemia, non-compliance to medications,
uncontrolled blood pressure, IHD, and development of renal failure.
1,2

Higher BP will increased the risk of worsening kidney function, while diabetic patients with microalbuminemia are at
increased risk of both CVD and progressive kidney disease.
4

KDIGO CPG suggested that those hypertensive patients with DM and non-dialysis CKD with urine albumin excretion
30-300 mg/day whose office BP is > 130/80 mmHg should be treated with and angiotensin-converting enzyme
inhibitors (ACE-I) or angiotensin II receptor blockers (ARBs) to maintain a BP 130/80 mmHg.
4

ACE-I are the first-line therapy in hypertension with DM and CKD, as well as CCF since ACE-I have been shown to
improve symptoms and survival, slow the progression of heart failure.
1,3,5
A low initiating dose should be given to
elderly patient, and slowly titrated up to the target dose as shown below:
1,2









Whereas for those patients who unable to tolerate with ACE-I, ARBs will be the alternative therapy.
1,3,5

Diuretics are indicated for fluid retention, combination with ACE-I are preferably for treating patient with heart failure
with preserved left ventricular systolic function to relieve dyspnoea and oedema.
2

Hoyt RE et al. mentioned that the trend in treating mild-moderate heart failure is to maximize the usage of ACE-I and
minimize/possibly stop the usage of loop diuretics because over-diuresis will activate both the sympathetic nervous
system and the renin-aldosterone systems, which will in turn aggravate heart failure.
1

According Malaysia CPG on management of heart failure, in patients with cardiac disease but do not as yet have
evidence of myocardial dysfunction should be treated appropriately with antiplatelet agents, -blockers, ACE-I and
statins.
2
Therefore, T. simvastatin 40mg ON and T. aspirin 75mg OD are given for this patient.
P Suggest to add T. Ramipril 1.25 mg OD.
Monitor blood urea, creatinine and serum potassium at 7-14 days after the initiation of ramipril. Stop the medication
if SCr level is > 20 % compared to baseline.
Monitor side effects of ACE-I (cough, hypotension, renal insufficiency, hyperkalaemia, angioedema).


DRP 2: Dosage adjustment of insulin in the management for uncontrolled diabetes mellitus.

S -
O Past Medical History: Diabetes Mellitus
Drug Dosage regimen Date start Date stop
SC Actrapid 6 units TDS 19/4/14 Ongoing
SC Insulatard 8 units ON 19/4/14 Ongoing

Blood glucose profile


Date 7 a.m. (Pre-breakfast) 11 a.m. (Pre-lunch) 5 p.m. (Pre-dinner) 10 p.m. (Pre-bed)
19/4/14 (mmol/L) 12.2 16.4 11.6 15.9
20/4/14 (mmol/L) 6.2 11.2 11.7 9.4
21/4/14 (mmol/L) 10.7
A The goals of monitoring the blood sugar profile is to adjust the insulin regimens in order to reach the blood glucose
target range.
6

Glycaemic Control Levels
Fasting 4.4-6.1 mmol/L
Non-fasting 4.4-8.0 mmol/L
HbA1c < 6.5 %
Dosage adjustment should not be made based on a single raised of blood glucose. However, the blood glucose need
to monitor closely at least for 48 hours to determine the effect of the insulin dose before making any dosage
adjustment.
7

Blood glucose target range and dose adjustment should be individualized.
7

Insulin dose adjustment for basal bolus regimen with 4 injections per day is shown as below:
7,8

Blood Testing
Times
Blood Glucose < 4 mmol/l or
Hypo
Blood Glucose 4-6 mmol/l Blood Glucose > 6 mmol/l
Pre-breakfast Reduce bedtime intermediate
insulin by 2 units
Maintain current dose Increase bedtime intermediate
insulin by 2 units
Pre-lunch Reduce morning short acting
insulin by 2 units
Maintain current dose Increase morning short acting
insulin by 2 units
Pre-dinner Reduce lunchtime short
acting insulin by 2 units
Maintain current dose Increase lunchtime short
acting insulin by 2 units
Pre-bed Reduce dinner meal short
acting insulin by 2 units
Maintain current dose Increase dinner meal short
acting insulin by 2 units

Each component of the insulin regimen affects only one blood glucose value. For example, if patient has elevated pre-
lunch blood sugar to > 6 mmol/l for 3 consecutive readings, then the dose of morning actrapid should be increased by
2 units.
7,8

Based on the pre-breakfast, pre-lunch, pre-dinner and pre-bed glucose level and comparing to the insulin dose
adjustment table, intermediate insulin (Insulatard) should be increased by 2 units, while morning, lunchtime and dinner
meal short acting insulin (Actrapid) should be increased by 2 units respectively.
7,8

Drug Dosage regimen (HKL) Dosage regimen (calculated)
SC Actrapid 6/6/6 8/8/8
SC Insulatard 8 units ON 10 units ON
Optimal dose for basal-bolus insulin:
8

Prandial insulin: 0.5 units/kg/dose
Basal: 0.4-0.5 units/kgh
Hypoglycaemia has become progressively more frequent with advanced duration of T2DM and the use of intensive
insulin therapy. Thus, it is important to recognize sign and symptoms, and treatment of hypoglycaemia as is has a
negative impact on physical and psychological well-being such as cardiovascular death, MI, cardiac arrhythmias,
cardiac ischaemic, progressive neuroglycopenia and autonomous nervous system abnormalities.
8

Sign and symptoms of hypoglycaemia:
8


P Adjust the SC Actrapid to 8/8/8 instead of 6/6/6, and SC Insulatard 10 units ON instead of 8 units ON.
Counsel the patient the importance of self blood glucose monitoring (SBGM) with correct method and timing: premeal
(breakfast, lunch, dinner) and pre-bed glucose levels (weekly fortnightly).
Educate patient the prevention and treatment of hypoglycaemia (e.g., hard candy).
HbA1c should be monitored every 3-6 months.

DRP 3: Management of anemia.

S Patient is having mild shortness of breath (SOB).
O 19/4/14 Lab data: Hb (*8.3 g/100mL), RBC (*2.9410
12
/L), HCT (*0.25), Platelets (*12710
9
/L), Proteinuria: 1+
Blood transfusion on 20/4/14 (due to anemia)
Blood product: 16 packed cell (IV Furosemide 20 mg in between transfusion)
Time: 8.25 pm - 2.25 am (No allergic reactions noted)
Vital sign during transfusion:
Schedule Time Pulse (p/min) Blood pressure (mmHg) Temperature (
o
C)
Baseline 8.25 pm 63 127/53 37
15 minutes 8.40 pm 64 131/50 37
30 minutes 9.10 pm 73 120/56 37
Hourly 10.10 pm 69 111/74 37
11.10 pm 63 101/75 37
12.10 am 60 121/70 37
1.10 am 64 118/84 37
2.10 am 61 105/63 37
Admission medication: T. Ferrous Fumarate 200 mg OD, T. Neurobion (Vitamin B1, B6, B12) 1 tablet OD
A The normal full blood count for adult females:
Haemoglobin level is 12-15 g/100mL.
Red blood count is 3.8-4.8 10
12
/L.
Haematocrit is 0.36-0.46.
Platelet count is 150-400 10
9
/L.
Patient is having anemia with symptoms (SOB) and laboratory investigations (low Hb, low RBC, low HCT).
Anemia is especially common in female, diabetic, CKD, and heart disease patients. It is estimated that 1/5 patients
with diabetes and stage 3 CKD have anemia, and its severity worsens with more advanced stages of CKD and in those
with proteinuria.
9,10,11

Anemia developed in CKD patients due to iron deficiency, diminished erythropoietin (EPO) secretion from kidney
failure and hyporesponsiveness to the actions of EPO. Proper attention to iron and folic acid stores is important as
deficiencies in these nutrients will secondarily complicate the anemia of kidney failure.
9,10,11

Blood transfusion is needed in patients with anemia who have CKD and do not require dialysis. The transfusion events
are more likely to occur at Hb levels < 10 g/dL.
12

During blood transfusion, vital signs (e.g., temperature, pulse rate and blood pressure) of patient should be recorded
before, periodically and after the completion of transfusion.
13

Goal of treatment is to correct anemia and to replenish body iron stores.
Ferrous fumarate is indicated for iron deficiency anaemia, 150 200 mg/day to correct iron deficiency and to replenish
iron stores.
14,15
Vitamin C may enhances iron absorption.
15

Folic acid 5 mg/day is indicated for folate deficiency while Vitamin B1, B6, B12 (Neurobion) is indicated for B12
deficiency; both are required for DNA synthesis.
14

P Suggest to continue T. Ferrous Fumarate 200 mg OD and T. Neurobion 1 tablet OD, but add on folic acid 5 mg OD
and Vitamin C 1000 mg OD.
Continue monitoring of haemoglobin, haematocrit and RBC count every 1 3 weeks until stabilised, then every 3
months for 1 year, then every year after.
14

CASE 2
Patient Database:
Demographic Data
Name: CKL Weight: - kg
Age: 7 years old Height: - cm
Gender: Female Date of admission: 20/4/2014
Race: Chinese MRN: 1915636

Chief Complaint
Referred from Changi General Hospital, Singapore for the treatment of NSTEMI and urosepsis
complicated acute kidney disease.

History of Present illness
Dysuria and fever for 2 days
Vomiting past 1 day

Past Medical History
No known underlying disease.

Family history
NA.

Social history
She is a widow, has 3 children and 6 grandchildren. She currently stay at Setapak with her
daughter. She smokes under stress.

Past Medication history
SC Fondaparinux sodium 2.5 mg STAT + OD Sublingual GTN PRN
T. Ciprofloxacin 500 mg BD T. Paracetamol 1 g PRN
T. Omeprazole 40 mg OD T. Atorvastatin 40 mg ON
T. Aspirin 100 mg OM T. Clopidrogel 75 mg OM

Allergy
No Known Drug Allergies (NKDA).

Review of system
BP: 103/43 mmHg RR: 16 b/min
PR: 85 p/min T: 36.5 C

Compliance evaluation
NA.

Physical examination
General: alert, pink, warm peripheral, good pulse volume, no tachycardia.
Lung: No crepitation.
CVS: DRNM.
Abdomen: soft, non-tender.

Diagnosis / Surgical procedure
Urinary Tract Infection (UTI) and NSTEMI.

Admission medication chart
Drug Dosage regimen Date start Date stop
T. Ciprofloxacin 500 mg BD 20/4/14 (D3) Ongoing
SC Fondaparinux 2.5 mg STAT + OD 20/4/14 Ongoing
S/L GTN PRN 20/4/14 Ongoing
T. Aspirin 100 mg OM 20/4/14 Ongoing
T. Clopidrogel 75 mg OM 20/4/14 Ongoing
T. Paracetamol 1 g PRN 20/4/14 Ongoing
T. Omeprazole 40 mg OD 20/4/14 21/4/14
IV Ranitidine 150 mg BD 21/4/14 Ongoing
T. Atorvastatin 40 mg ON 20/4/14 21/4/14
T. Simvastatin 20 mg ON 21/4/14 Ongoing

Significant laboratory data
(a) Full blood count
Day & Date

N. Range
1 2 3 4 5 6 7 8
19/4 20/4 21/4 22/4


TWBC 411 x10/L 12.1
Hb 11.5-16.5
g/100mL
12.2
RBC 4.5-6.3x10
6

HCT 37-48%
Platelet 150-400x10/L 176

(b) Renal profile
Urea 1.7-8.3 mmol/L 7.4
Na 135-145 mmol/L 134
K 3.5-5.0 mmol/L 3.9
Cl 96-106 mmol/L 101
Ca 2.1-2.6 mmol/L
Mg 0.7-1.3 mmol/L
PO4- 0.8-1.45 mmol/L
SCr 64-122 umol/L 105
ClCr 105-150 Ml/min

(c) Cardiac enzyme
CK 24 195 u/l 811
LDH 0 248 u/l
AAT <37




(d) Others
RBS 8.9
Troponin T 0-29 ng/L 217
CKMB < 5 ng/mL 8.06

(e) Vital signs
BP 103/43 127/75 128/50 120/87
TEMP 36.5 37 37



RR 20 25 b/min 16 20 20 19
PR 90 100 p/min 85 53 51 76

(f) Lipid
Date 19/4
T. Chol < 5.7 mmol/L 4.7
C-TG < 1.7 mmol/L 0.77
C-HDL > 1.7 mmol/L 1.18
C-LDL < 3.9 mmol/L 3.17

















Drug-related problems / Pharmaceutical care issues
DRP 1: Inappropriate drug selection of antibiotic for urosepsis.

S Patient complains of fever, chill and cannot urinate or control urination for the past 2 days
before admitted to Changi General Hospital, Singapore.
O She is diagnosed with NSTEMI and urosepsis complicated acute kidney disease.
She is prescribed with T. Ciprofloxacin 500 mg BD.
A Urosepsis is a condition that the urinary tract infection (UTI) progress further and
the microorganisms enter the blood stream, which can be a life-thretening illness and
affect other organ in the body.
16

Elderly, diabetic, immunosuppressed patient and those with acquired
immunodeficiency syndrome are more likely to develop urosepsis.
16

E.coli, Kebsiella, Proteus, Enterococcus, Pseudomonas and Methicillin-resistant
Staphylococcus aureus (MRSA) are the most susceptible organisms.
17

According to National Antibiotic Guideline 2008, IV cefepime 1g every BD or IV
imipenem/Cilastatin 500mg TDS is preferred for urosepsis.
17

Cefepime is the 4
th
generation cephalosporin which has extended spectrum of
antibacterial activity that includes both aerobic gram negative bacteria
(Enterobacter, Escheichia coli, Klebsiella pneumonia, Proteus mirabilis, Neissria
meningitidis and pseudomonas aeruginosa) and gram positive bacteria
[Staphylococcus aureus (methicillin-susceptible strains only), Streptococcus
pneumonia and Streptococcus pyogenes (Lancefields Group A streptococci)].
18

Imipenem/Cilastatin is carbapenem that cover gram-positive bacteria (methicillin-
sensitive S.aureus and Streptococcus spp), resistant gram-negative bacilli (extended
spectrum beta-lactamase-producing Escherichia coli and Klebsiella spp,
Enterobacter spp, and Pseudomonas aeruginosa) and anaerobes.
19

However in this case, Ciprofloxacin have been used and it cover gram-positive
microorganisms [methicillin-susceptible staphylococcus aureus (MSSA),
streptococcus pneumonia], gram-negative microorganisms (enterobacteriaceae,
H.influenzae, haemophilus spp, N. gonorrhoeae, N. meningitides, M. catarrhalis, P.
aeruginosa, S. maltophilia], and atypical legionella pneumophilia.
20

Culture and sensitivity test should be done to find out what kind of bacteria is causing
the infection and to see what antibiotic should be choosed.
17
However, there are no
culture and sensitivity test done on this patient before and after starting the
medication.
P Culture and sensitivity test is recommended.
Suggest start with IV cefepime 1g BD instead of T. Ciprofloxacin 500mg BD.
Monitor renal function, and signs and symptoms of anaphylaxis during first dose of
cefepime. The side effects of included diarrhea, abdominal pain, nausea, dyspepsia,
flatulence and loose stools.
19

Measure total white blood cell and body temperature to observe the effect of the
medication.


DRP 2: Appropriateness of initiating beta blocker in NSTEMI.

S -
O Patient is diagnosed with NSTEMI.
Admission medication:
Drug Dosage regimen Date start Date stop
SC Fondaparinux 2.5 mg STAT + OD 20/4/14 Ongoing
S/L GTN PRN 20/4/14 Ongoing
T. Aspirin 100 mg OM 20/4/14 Ongoing
T. Clopidrogel 75 mg OM 20/4/14 Ongoing
T. Atorvastatin 40 mg ON 20/4/14 21/4/14
T. Simvastatin 20 mg ON 21/4/14 Ongoing
Lab test:
Laboratory test Normal level 19/4
CK 24-195u/l 811
Troponin T 0-29ng/l 217
CK-MB <5ng/mL 8.06
a
A Medication therapy should be started in the management of NSTEMI for
intermediate/high risk patient. This patient is having elevated cardiac biomarkers, so
she is an intermediate/high patient.
21,22

The initial medications include anti-thrombotics , beta-blockers, statins and nitrates,
while angiotensin converting enzyme inhibitors (ACE-I)/angiotensin receptor
blockers(ARBs), with or without calcium channel blockers (CCBs) is indicated for
certain condition.
21,22

According to Malaysia CPG on UA/NSTEMI and Sarawak handbook,
intermediate/high risk patient should be initiated with aspirin, clopidogrel,
unfractionated heparin or low molecular weight heparin or fondaparinux, with or
without platelet GP IIb/IIIa receptor antagonist need to be administered.
21,22

Soluble/chewable tablet of aspirin 300 mg should be given as the loading dose, while
soluble / enteric coated aspirin 75-150 mg daily is recommended as the maintenance
dose since > 300-325 mg/day associated with increased risk of minor bleeding
without greater efficacy.
21,22

Whereas for clopidogrel, loading dose 300-600 mg follow by maintenance dose
75mg/day is recommended.
21,22

Fondaparinux (factor Xa inhibitor) with 2.5mg SC daily is given for 8 days.
21

Nitrate (GTN sublingual glyceryl trinitrate) 0.5mg is given to patient for
symptomatic relief. Use 1 tablet GTN every 5 minutes for 3 doses during attack.
21,22

High dose statin should be initiated soon after admission in order to reduce major
adverse cardiac events.
21,22

-blockers should be given if there are no contraindications like marked first degree
AV block, second or third degree AV block, history of bronchial asthma, severe
peripheral arterial disease, acute decompensate LV dysfunction or cardiogenic
shock.
21,22,23

-blockers competitively block the effects of catecholamine on cell membrane beta
receptors, inhibition of catecholamine reduces myocardial contractility, sinus node
rate and AV node conduction velocity. Through these action, they can reduce
myocardial oxygen demand by inhibiting increase in heart rate and myocardial
contractility caused by adrenergic activity.
22

ACE-I/ARB is also recommended for patient with LV dysfunction.
21

If patient unable to tolerate with -blockers, continuing or recurring angina despite
adequate doses of nitrates and -blockers and during variant angina, CCB should be
given, but need to avoid short acting dihydropyridine CCB (nifedipine).
21

P Supplement oxygen should be given when arterial saturation less than 90%, ECG
should be monitor continuously.
Add atenolol 25mg OD to this patient and titrate gradually to 100mg OD.
Monitor the systolic blood pressure and pulse rate when beta-blocker being
administered. Withhold the -blocker if systolic BP < 100 mmHg / pulse rate < 50
p/min.
Monitor side effects like persistent bradycardia, hypotension, chest pain, edema.
Monitor the risk of bleeding when using anti-thrombotic therapy.
Check liver function test and creatinine kinase if patient on statin. Withhold the statin
if the level is markedly increased.





















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