Posted: March 3rd, 2020

Pharm Questions essay

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Case Study: Angina and ACS

After reviewing the case, please provide answers to the questions that follow. Concise, bulleted answers are highly preferred. Points will be removed for lengthy answers.

1st Visit

Background:

NG is a 52-year-old white male reports to clinic with a 1-month history of chest pain and shortness of breath that began after turning over new flower beds for his wife. At first, the pain was heavy, and located in the center of his chest. It resolved when he stopped shoveling and rested. When he tried to dig again, the pain returned. He stopped and asked his son to finish the digging. The pain has not recurred with his normal level of activity but does recur with greater than normal exertion.

Vitals:

· Blood pressure: 152/94 mmHg

· Pulse: 94 bpm

· Respiratory rate: 22/min

· Temperature: 98.6

· Height: 5’11”

· Weight: 252 pounds (up 22 pounds since last visit about 2 years ago)

· Chest Pain: 0/10

PMH:

· Hypertension

· Tobacco abuse disorder

· Overweight status

Social History:

· 32 pack year history of smoking, currently 1.5 – 2 packs per day

Current Medications:

· Hydrochlorothiazide 12.5 mg daily

Fasting Labs:

Today’s Value

Normal Range

Sodium Level (SOD)

140

136-146 mMol/L

Potassium Level (POT)

4.2

3.5-5.0 mMol/L

Chloride (CHLOR)

105

98-108 mMol/L

CO2 (CO2)

26

22-34 mMol/L

Urea Nitrogen (UN)

14

8-20 mg/dL

Creatinine Level (CREAT)

1.0

0.5-1.0 mg/dL

Glucose Level (GLUC)

152

73-110 mg/dL

Calcium Level (CAL)

9.6

8.6-10.3 mg/dL

Cholesterol (CHOL)

248

1-200 mg/dL

Triglycerides (TRIG)

148

1-150 mg/dL

High Density Lipoprotein Chol (HDL)

34

40-60 mg/dL

Low Density Lipoprotein Chol (LDLC)

194

1-129 mg/dL

Hemoglobin A1c

6.9

4.2-5.6%

2nd Visit

Background:

A little more than two months later NG reports to clinic with a 1 month history of chest pain and shortness of breath on exertion. He reports that the chest pain comes on when he goes out to smoke and/or walks the dog, now usually after walking for approximately 1/2 block. He notes that the pain is probably a little worse if he walks faster or for a longer time. He feels very winded at that time as well. He admits that he has not been able to quit smoking and has stopped trying. To help with the chest pain, he will rest, and the chest pain resolves after approximately 25 minutes. He notes that he has also occasionally had this sort of discomfort in the past, but only when mowing the lawn or shoveling snow or other very strenuous activity, and that it resolved upon stopping. It seems to be that he cannot even do as much as he used to without the pain coming on. He has not treated the pain with any medication to date. He also admits that his diet has been very poor, he has been under a great deal of stress at work, and he has been doing little exercise. He has not wanted to use the nitroglycerin because the one time that he did, so he got a bad headache. His chest pain did improve, but he feels it would have if he rested and not taken the nitroglycerin. He admits that he has not been taking his aspirin daily because he did not feel any better when he took it. He has been taking his metoprolol and atorvastatin as directed. He denies chest pain currently—he is sitting and at rest.

Objective Data at Visit 2:

· 32 pack year history of smoking, currently 2 – 2.5 packs per day

Vitals: obtained this morning are as follows

· Blood pressure: 149/90 mmHg

· Pulse: 86 bpm

· Respiratory rate: 22

· Temperature: 98.6

· Height: 5’10”

· Weight: 260 pounds (up 8 pounds since last visit)

· Chest Pain: 4/10 after he walked in from parking lot, now 2/10 after resting 15 minutes

Current Medications:

· Hydrochlorothiazide 12.5 mg daily

· Metoprolol tartrate 25 mg twice daily

· ASA 81 mg daily (patient states he has not been taking)

· NTG 0.4 mcg SL prn (used once, but none since)

· Atorvastatin 80 mg daily

3rd Visit

Background:

It is decided that NG should have another stress test. NG’s stress test shows a hypokinetic region of the apical portion of the heart. While undergoing the stress test, he develops severe chest pain and is taken to the hospital. Troponin levels were checked and found to be elevated. He is diagnosed with Acute Coronary Syndrome. A PCI is performed, and a drug eluting stent placed. One week after treatment and release, he is back in clinic for discharge follow up. He also was diagnosed with new onset Type II diabetes and started on metformin. He has had some chest pain since discharge and has used nitroglycerin 2 times. Chest pain resolved on use.

Objective Data at Visit 3:

· Stopped smoking while in hospital and has not resumed

Vitals:

· Blood pressure: 149/92 mmHg

· Pulse: 62 bpm

· Respiratory rate: 22

· Temperature: 98.6

· Height: 5’10”

· Weight: 236 pounds

· Chest Pain: 0/10

Current Medications:

· Hydrochlorothiazide 12.5 mg daily

· Metoprolol tartrate 50 mg twice daily

· Clopidogrel 75 mg daily

· ASA 81 mg daily

· NTG 0.4 mcg SL prn

· Metformin 500 mg BID

· Atorvastatin 80 mg daily

Other Studies:

· EF determined to be 38% by TEE

Fasting Labs:

Today’s Value

Normal Range

Sodium Level (SOD)

142

136-146 mMol/L

Potassium Level (POT)

4.1

3.5-5.0 mMol/L

Chloride (CHLOR)

105

98-108 mMol/L

CO2 (CO2)

26

22-34 mMol/L

Urea Nitrogen (UN)

12

8-20 mg/dL

Creatinine Level (CREAT)

1.0

0.5-1.0 mg/dL

Glucose Level (GLUC)

131

73-110 mg/dL

Calcium Level (CAL)

9.6

8.6-10.3 mg/dL

Cholesterol (CHOL)

252

1-200 mg/dL

Triglycerides (TRIG)

154

1-150 mg/dL

High Density Lipoprotein Chol (HDL)

30

40-60 mg/dL

Low Density Lipoprotein Chol (LDLC)

186

1-129 mg/dL

Hemoglobin A1c

7.0

4.2-5.6%

1. Would prasugrel (Effient) have been an appropriate choice for a P2Y12 inhibitor for this patient? Why?

0. How long should he be treated with P2Y12 inhibitor therapy?

0. What risk factors need to be addressed?

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