CASE ON CCF WITH OLD
IHD,TYPE-II DM,HTN AND
CKD
ANANTHU R KRISHNAN
II PHARM D
ROLL NO.7
INTRODUCTION
ABOUT DISEASE
CONJECTIVE CARDIAC FAILURE :It is a clinical syndrome
caused by inability of heart to pump sufficient blood to meet the body’s
metabolic needs . HF can result from any disorder that affects the ability
of heart to contract or relax .
IHD : It is defined as lack of oxygen and decreased blood flow to
myocardium resulting from coronary artery narrowing or obstruction.
Short term of breath and chest pain, chest tightness are symptoms of IHD.
TYPE II DM : Diabetes mellitus(DM)is a group of metabolic disorder
characterized by hyperglycemia and abnormalities in carbohydrate ,fat ,
and protein metabolism.it may result in chronic microvascular and
neuropathic complication.
It is two types . Type I DM (IDDM) and Type II DM (NIDDM).
The DM patients will have polyuria ,polyphagia, and polydipsia. Type 2
DM occurs due to insulin resistance.
• HYPERTENSION (HTN) : it is a common condition that
is defined as persistently elevated arterial blood pressure.
Also known as silent killer. Normal value of blood pressure
is 120/80 mm of Hg.
CHRONIC KIDNEY DISEASE (CKD) : is defined by a
reduction in the glomerular filtration rate (GFR) and or
urinary abnormalities or structural abnormalities of the renal
tract.
PATIENT DEMOGRAPHIC
DETAILS
Name : abc
Age : 65 years
Gender : Male
IP no : 87443/2018
Ward : Male medical ward
DOA : 09-09- 2018
DOD : 00-00-0000
ALLERGIES : Nil Known allergies
SUBJECTIVE
A 65 years old male patient was admitted to the
male medical ward with complaints of
breathlessness since 8 days, B/L pedal edema
8 days, irrelevent speech 1 week.
The patient had a known case of diabetes ,
hypertension since 9 years .IHD since 2
months , CKD on MHD.
Patient was taking AMLODIPINE(5mg),
ATORVASTATIN(40mg), INSULIN (6-6-1)
objective
• On Examination,
CNS: Conscious oriented
CVS: S1, S2 +ve , No murmur
BP : 180/110 mm of Hg
PR : 90 bpm
RS : B/L crepts +ve, B/L NVBS +ve
P/A : soft and non tender , no organomegaly
EDEMA : + VE
ADVICE
• RFT
• CBC
• SERUM ELECTROLYTES
Laboratory parameters
Parameters Observed Value Reference range
hemoglobin 11.7g/dl 14-18g/dl
FBS 150mg/dl <100mg/dl
potassium 6.4 meq/l 3.5-5 meq/l
Chloride 116 meq/l 97-107 meq/l
WBC 9500 4500-11000cells/cmm
Serum creatinine 3.2 mg/dl 0.6-1.2mg/dl
Serum urea 80mg/dl 20-50mg/dl
Sodium 3.4 mMOL/L 3.5-5.0 mMOL/L
Provisional diagnosis
CCF
IHD
TYPE 2 DM
CHRONIC KIDNEY DISEASE
HYPERTESION
assessment
Based on subjective evidences like breathlessness since 8 days , B/L
pedal edema since 8 days, irrelevant speech since one week, and
K/C/O DM and HTN since 9 years, IHD since 2 months ,CKD on
MHD
And objective evidences like increased BP and PR , presence of edema
and abnormal lab values the patient diagnosed with
CCF
IHD
TYPE 2 DM
HYPERTENSION
CKD
planning
GOALS OF THERAPY
To ameliorate the active symptoms like
breathlessness, edema etc.
To normalize the blood glucose level.
To maintain the blood pressure level in normal range.
To arrest the progression of kidney damage.
To optimize the renal functions.
To prevent complications.
To enhance the patient quality of life.
Treatment plan
Sl DRUG PRESCRIBED (GENERIC NAME) DOSE ROUTE FREQ D D. D.
no: .1 2 3
1 INJ. FUROSEMIDE 40mg IV 1-1-0
2 TAB. ASPIRIN 150mg PO 0-1-0
3 TAB. CLOPIDOGREL 75mg PO 0-1-0
4 TAB. CARVEDELOL 300/75mg PO 1-0-1
5 TAB.VitD3+CaCO3 500mg PO 0-1-0
6 TAB.ISOSORBIDE DINITRATE 3.75mg PO 1-1-1
7 TAB. NaHCO3 25mg PO 1-1-1
8 TAB.FOLIC ACID 5mg PO 0-1-0
9 TAB. FERROUS FUMERATE 300mg PO 1-0-1
10 INJ. PANTOPRAZOLE 40mg IV 1-1-0
11 TAB. AMLODIPINE 5mg PO 1-1-1
12 TAB. ATORVASTATIN 40mg PO 0-0-1
13 INJ. INSULIN R SC 6-6-1 - -
Physician's notes
DAY 2
• PR :84 bpm
• BP : 170/90 mmHg
• Systemic examination normal
LABORATORY READINGS
Blood urea :91 mg/dl
Creatinine:4.1mg/dl
Hb : 11.7g/dl
WBC : 12600 cell/cmm
Potassium: 7 meq/l
DAY3
No fresh complaints.
• PR : 84 bpm
• BP : 164/90 mmHg
• Systemic examination normal
• CST
PHARMACIST
INTERVENTIONS
There is no proper evidence for diagnosing CCF.
MONITORING PARAMETERS
• DISEASE RELATED
• Monitor BP &PR
• Monitor signs and symptoms
• Monitor serum urea and serum creatinine.
• Monitor blood glucose level .
• DRUG RELATED
• FUROSEMIDE : Monitor renal functions and serum electrolytes.
• ASPIRIN : Reduced incidence of stroke and transist ischemic attack
indicates efficacy.
• CARVEDILOL: Decreased signs and symptoms of cardiac failure ,
hypertension , and renal function.
• ISOSORBIDE DINITRATE : Reduction in frequency and severity of
angina attacks may indicate efficacy.
• FERROUS FUMARATE : Monitor hemoglobin and RBC count.
DRUG INTRACTIONS
• Concurrent use of AMLODIPINE and CLOPIDOGREL may result in
decreased antiplatelet effect and increased risk of thrombotic events
• Concurrent use of LOOP DIURETICS and NSAIDS may result in reduced
diuretic effectiveness and possible nephrotoxicity.
• Concurrent use of ASPIRIN and CLOPIDOGREL may result in an increased
risk of bleeding
• Concurrent use of ASPIRIN and ALUMINUM, CALCIUM OR
MAGNESIUM CONTAINING PRODUCTS may result in decreased
salicylate effectiveness.
• Concurrent use of BETA-ADRENERGIC BLOCKERS and NSAIDS may
result in increased blood pressure
• Concurrent use of CLOPIDOGREL and CYP3A4 METABOLIZED
STATINS may result in decreased formation of clopidogrel active metabolite
resulting in high on-treatment platelet reactivity.
• Concurrent use of IRON and PANTOPRAZOLE may result in reduced iron
bioavailability.
• Concurrent use of ANTIDIABETIC AGENTS and SELECTED DIURETICS
may result in increased hyperglycemia risk; increased insulin requirement.
GOALS ACHIEVED
• The patients blood pressure became to a
normal level.
• Signs and symptoms got reduced.
PATIENT COUNSELLING
ABOUT DISEASE
CHRONIC KIDNEY DIASEASE : It is defined as
abnormalities in kidney structure or function present for 3
month or longer, with implications for health , eventually,
the patient has permanent kidney failure.
CCF : it is a clinical syndrome caused by inability of heart to
pump sufficient blood to meet the body’s metabolic needs
Use of sodium should be decreased because ,if it is too much
your body holds on to water so heart needs to work hard
Eat foods having high fiber ,fresh fruits ,vegetables.it can
control the blood sugar and lower cholesterol
Main symptoms include chest pain, chest tightness,short
breath.
• IHD:it is defined as the lack of oxygen or decreased blood flow
to the myocardium result in the coronary artery narrowing or
obstruction.
• Eat apple and honey for the important role in the blood
circulation of human body.
• Consume raw onion juice to control the cholesterol level in the
blood
• Vitamin E essential to enhance the level of oxygen in the
blood .Green leafy vegetables like cabbage which is rich in
source of vitamin E should be included in the diet.
• Its main symptoms are chest pain,lightheadedness,chest
tightness.
HYPERTENSION is a very dangerous chronic condition. It
is defined as elevated arterial blood pressure. It can lead to
following effects such as
Cardiac effects(angina pectoris ,MI), Renal effects(renal
failure, hypertensive nephrosclerosis)
Cerebral effect(cerebral infraction and haemorrhage, lacunar
syndrome)
ABOUT MEDICATIONS
Tab. Iron + Folic acid: Black tarry stools is the main
ADR.
Insulin:Take within 30 min of meal,move the injection
site on each use.
Patient is advised to take all the medications properly
with correct dose ,right time,right frquency,for the
complete regimen as prescribed.
The patient is also advised to consult the doctor
if any unusual effects are seen
LIFE STYLE MODIFICATION
Diet
• DASH Therapy : Include vegetables & fruits in diet.
• Reduce salt intake.
• Include green leafy vegetables.
• Avoid banana.
• Control fluid intake to prevent fluid overload.
• Avoid junk foods and soft drinks.
• Limit protein intake.
• Have iron rich food such as black currants, dried dates, bajra
etc.
• Avoid excess consumption of tea and coffee(less than 2 cups
per day.)
Exercise at least 30 minutes five times per week.
Maintain BMI in between 20 to 25kg/m2.
Thank you
