Case Studies With Solved Answers

Submitted To: MNS, Phd

Professor, Dept.of pharmaceutical
sciences
north south
university

Name: Sufia Akter

ID: 2415082072
Section 01
CASE:01:Tanvir Ahmed
A 60-year-old man is brought to A&E with central crushing chest pain.
He has been in pain for several hours and it was not relieved by
nitroglycerin. The man was feeling nauseous and was very anxious. His
blood pressure was 140/75. An ECG revealed ST segment elevation,
pathological Q waves and inversion of the T wave in leads II, III and aVF.
A diagnosis of acute inferior myocardial infarction (MI) was made.
Question:
(a) What drugs should be administered immediately to this patient?
(b) What contraindications should you consider?
(c) What drugs would you prescribe for this patient to take long-term
when he returns home?
Solved Answers
1. Aspirin is an appropriate immediate treatment for a suspected MI.
Nitroglycerin or opioids may be used to help with chest pain;
however, they do not improve overall outcomes. Supplemental
oxygen is recommended in those with low oxygen levels or
shortness of breath.
2. The one true contraindication to giving nitrates in patients with
chest pain is hypotension. The patients with possible inferior MI
should not be given nitrates (or be given with cautious) due to the
potential for right-sided heart involvement and need for high
preload to maintain blood pressures.
3.
Aspirin 75mg – OID
Rosuvastatin 40mg – Once at bedtime
Bisoprolol 5mg – Once at morning
Ramipril 2.5mg - once a day for 1 week. For the next 3 weeks, the dose
is 5 mg per day
 CASE:02; Fahmida Haque
A 61-year-old man, Mr. Kamal with Type II diabetes mellitus presents to the emergency room,
complaining of “heaviness” in his chest. He says the discomfort began as a pressure pain
sensation in the middle of his chest shortly after starting to shovel snow from his driveway. He
is sweaty and complains of nausea. He says the pain subsided somewhat when he sat down,
but has persisted as a heaviness.
PMI: Mr. Kamal has had mild chest pain in the past, which he attributed to indigestion. He
says this is very different. He is a 2-pack-per-day smoker, has 2–3 alcohol drinks daily, and
works as a litigation attorney.
Physical Examination: Mr. Kamal is obese and holding his fist over his sternum in apparent
mild-moderate discomfort.
Vitals signs: HR 110; BP 145/95; RR 22; Temp. 37°C (98.6°F); SpO2 92% on room air. Head
and neck examination reveal no elevation of Jugular Venous Pressure (JVP), and a rapid
carotid pulse. He has a third heart sound and a systolic murmur heard over the lower left side
of his sternum. His peripheral pulses are decreased, and his capillary refill is delayed. His
abdominal and respiratory examinations are unremarkable.
Investigation: The triage nurse, ordered an electrocardiogram (ECG, or EKG) (see Figure 1).

Questions:
1. What is the most likely diagnosis of
this patient?
2. What would you expect to find on his Figure 1: Anterior Q waves (V1-4) with ST
ECG and why does this patient have a third elevation due to acute MI.

heart sound?
3. What laboratory tests would help confirm this diagnosis?
4. What therapeutic measures will you take as a pharmacist to improve patient's condition initially?
Answers
1. Symptoms indicated the patient may be suffering from Myocardial Infarction or severe
angina pectoris i.e it could be unstable

2. ST-segment elevations in the precordial leads generally demonstrate anterior

myocardial infarction. However, there are several cases of RVMI presenting with
precordial ST-segment elevations on ECG. Right Ventricular Myocardial Infarction is
predominantly a complication of inferior myocardial infarction
The third heart sound (or, S3) occurs early in diastole and is best heard with expiration
while lying on his/her left side. It may indicate significant ventricular dysfunction. In this
patient, damage to the cardiac muscle may be making the ventricle less responsive to the
normal filling from atria.
3.
Electrocardiogram (EKG): This test, which shows electrical activity in
the heart like a wave pattern (described above), is key to diagnosing a
STEMI.
Imaging: The most common imaging test used with suspected heart
attacks is echocardiography. This test uses ultra-high-frequency sound
waves to create an image of your heart, including the internal
structure.
- Computed tomography (CT) scan: This test uses X-rays and computer
processing to generate a highly detailed, layer-by-layer view of the
heart.
Magnetic resonance imaging (MRI): This test uses an extremely
powerful magnet and a computer to process images and create high-
resolution pictures of the heart.
Troponin test
PAPP test
CK-MB test
4.
• Percutaneous coronary intervention (PCI)
Primary percutaneous coronary intervention (primary PCI) is an
emergency treatment of a STEMI. It's a procedure to widen any blocked
coronary arteries.
Initial medical management of STEMI consists of relief of ischemic pain
with nitrates and morphine, antithrombotic measures including
antiplatelet agents (aspirin, thienopyridines and glycoprotein IIb/IIIa
inhibitors), and systemic anticoagulation (heparin or bivalirudin) and
beta-adrenergic blockade.
CASE:03; Mahjabin Mostofa
• A 60-year-old man is brought to A&E with central crushing chest pain.
He has been in pain for several hours and it was not relieved by
nitroglycerin. The man was feeling nauseous and was very anxious. His
blood pressure was 140/75. An ECG revealed ST segment elevation,
pathological Q waves and inversion of the T wave in leads II, III and aVF.
A diagnosis of acute inferior myocardial infarction (MI) was made.
• 1. What drugs should be administered immediately to this patient?
• 2. What contradictions should you consider?
• 3. What drugs would you prescribe for this patient to take long-term
when he returns home?
Solved Answers
1. Aspirin is an appropriate immediate treatment for a suspected MI.
Nitroglycerin or opioids may be used to help with chest pain;
however, they do not improve overall outcomes. Supplemental
oxygen is recommended in those with low oxygen levels or
shortness of breath.
2. The one true contraindication to giving nitrates in patients with
chest pain is hypotension. The patients with possible inferior MI
should not be given nitrates (or be given with cautious) due to the
potential for right-sided heart involvement and need for high
preload to maintain blood pressures.
3.
Aspirin 75mg – OID
Rosuvastatin 40mg – Once at bedtime
Bisoprolol 5mg – Once at morning
Ramipril 2.5mg - once a day for 1 week. For the next 3 weeks, the dose
is 5 mg per day
 Case: 04; Anika Rodela

Mr FG a 69-year-old retired school teacher who was admitted to the emergency department complaining
of severe chest pain after climbing stairs of his daughter’s house. In ambulance he is administered aspirin
300 mg. on arrival at the hospital and subsequent examination and review by the admitting doctor the
following information is obtained.
Previous Medical History
1.Hypertension (10 years) 2.Type-2 diabetes mellitus (recently diagnosed, currently diet controlled) 3.
The patient is regular cigarette smoker (>40 per day)
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 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 bpm, regular
■ Respiratory rate 15 breaths per minute
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
Questions
1. What further diagnostic and biochemical tests should be ordered to help confirm the diagnosis?
2. What should be the initial treatment for this emergency situation?
3. What classes of drugs should be initiated as standard secondary prevention treatment following acute myocardial
infarction in this patient?
4. If this patient is initiated on a statin as cholesterol-lowering treatment, when should the total cholesterol next be
checked following drug initiation?
5. What counselling should the patient receive regarding the side-effects of statins?
Answers
• 1. Troponin: Troponin enzymes consist of troponin T, C, and I which
are located within cardiac and skeletal muscle. Cardiac isoforms of
troponin T and I are exclusively expressed in cardiac myocytes. They
act as sensitive and specific markers of cardiac damage.
• CK-MB: A more specific marker is creatine kinase MB (CK-MB), which
is an isoenzyme of creatine kinase that is more specific for cardiac
muscle damage. CK or CK-MB will rise approximately 4 hours after an
acute cardiac event will reach a peak after approximately 24 hours
and will remain raised for 3–4 days.
2.
heparin 5000 units stat
alteplase 10 units i.v. bolus followed by a further 10 unit i.v. bolus after
30 minutes
morphine 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
3.
Beta-blockers –
Statins
ACE inhibitors
Antiplatelet therapy with aspirin.

4. After 6–12 weeks. A minimum interval of at least 4 weeks

5.
Simvastatin, like other inhibitors of HMG-CoA reductase, occasionally
causes myopathy manifested as muscle pain, tenderness, or weakness
with creatine kinase (CK) 10 times above the upper limit of normal
(ULN). Myopathy sometimes takes the form of rhabdomyolysis with or
without acute renal failure secondary to myoglobinuria, and very rare
fatalities have occurred. All patients starting therapy with a statin, or
whose dose of statin is being increased, should be advised of the risk of
myopathy and told to report promptly any unexplained muscle pain,
tenderness or weakness.
Case : 05; Maliha Patwary
• Mr Peter is a 52-year-old active school teacher. Four years ago he was found to have a
raised TC and elevated blood pressure for which he was started on 10 mg simvastatin
and 2.5 mg bendroflumethiazide. Over the years his dose of simvastatin has been
gradually increased to 40 mg a day, but apart from this his medication has remained
unchanged. He presents at the clinic complaining of aches and pains in his legs over the
past 10 days. On questioning he reveals that over recent months he has been eating
fresh grapefruit and consuming the occasional glass of grapefruit juice. A tentative
diagnosis of myopathy is initially made.
• Questions
• 1. What is the likelihood that grapefruit juice has contributed to Mr Peter's problem?
• 2. Are any additional biochemical tests warranted?
• 3. Would atorvastatin, rosuvastatin or pravastatin be a more appropriate statin to
prescribe if Mr Peter’s wanted to continue with the occasional glass of grapefruit juice?
Answers
1. Grapefruit juice increases the area under the plasma
concentration–time curves of simvastatin into many times-fold. It
has been suggested that it is the furanocoumarin in the grapefruit
juice which binds to CYP3A4 and inactivates it in both the liver and
the gastro-intestinal tract. When taken on a regular basis this can
increase the risk of dose-related side effects such as rhabdomyolysis
and increase the risk of myopathy.
2. Creatine kinase (CK) level should be checked in patients complaining
of significant muscle pain to exclude overt myopathy.
Troponin Test
3. Atorvastatin is also metabolised by CYP3A4. Although the effect is less dramatic than
with simvastatin, the concurrent intake of large quantities of grapefruit juice with
atorvastatinis not recommended. Neither pravastatin nor rosuvastatinis substantially
metabolised by P 450 and may be better alternatives. However, when there is a past
history of myopathythe need for caution remains as the risk of recurrence is enhanced
whatever lipid-lowering agent is prescribed. It should also be noted that rosuvastatin,
unlike pravastatin, has no clinical outcome data and would not be appropriate for use in
this patient.
There are also separate concerns regarding the muscle toxicity of rosuvastatin,
especially when used at the higher dose of 40 mg. This again would indicate that
rosuvastatin is not the best option for Mr Peter. As this patient is being treated with a
statin for primary prevention, National Institute of Health and Clinical Excellence(2008a)
guidelines suggest that only generic statin agents are cost-effective and, therefore,
pravastatin should be considered as a first-line alternative for this patient.
Case 06; Monia Akter
Mr. Rahman is a 46-year-old Product Executive working for a large, multinational
company who works long hours and frequently has to travel abroad. He has a
family history of CHD, and 9 months ago he attended a coronary screening clinic for
a health check.
At the clinic he was found to have a normal blood pressure (132/84 mmHg) but a
blood screen revealed a TC of 5.7 mmol/L and triglycerides of 11.8 mmol/L. When
he revisited the clinic 4 weeks later after trying to follow dietary advice, a fasting
blood sample revealed a TC of 5 mmol/L and triglycerides of 2.7 mmol/L. Liver
function tests were normal. He is a non-smoker and claims never to drink more
than 10 units of alcohol per week. His BMI is 27 kg/m2. After repeated requests to
revisit the clinic he eventually turned up stating he had been away from home for 6
months on a series of business trips. He was trying to keep to a low-fat diet and his
blood profile revealed TC 5.7 mmol/L, triglycerides 4.3 mmol/L, HDL-C 0.7 mmol/L
and LDL-C 3 mmol/L, non-HDL-C 5 mmol/L.
Questions
1. Is Mr. Rahman at high risk of CHD?
2. Is Mr. Rahman a candidate for lipid-lowering therapy?
3. Should Mr. Rahman’s children be screened for dyslipidemia?
Answers
1.
Mr. Rahman would appear to have a mixed lipidemic, although it is difficult to
interpret non-fasting triglycerides because of the influence of food intake.
The low HDL-C and raised BMI indicate he is overweight and/or has a non-
ideal lifestyle. Exclusion of diabetes, high alcohol intake, liver and renal
impairment is necessary. The possibility of impaired glucose tolerance should
not be overlooked and a hemoglobin A1c level should be checked.
2.
the elevated triglycerides and TC, Mr. Rahman is certainly a candidate for
lifestyle advice. The use of a statin should be considered if the lifestyle
changes do not bring about the necessary improvements in the lipid profile.
He can be treated with low dose of statin medication.
Answers
3.
The family history of CHD is important but is only significant if the age
of onset in a parent or sibling was younger than 60 years. In this case,
the children should have CV risk assessment undertaken every 5 years
from the age of 40 years. However, were a rare familial disorder, for
example, familial dysbetalipoproteinemia, be identified as the causative
factor, his children should be screened after puberty because the
offending gene may not express itself in the younger child
Case 07; Umma Shafia
• Case study on Angina
• Mr AG, a 57-year-old taxi driver of Indian origin, attends your community pharmacy
with a new prescription for: glyceryl trinitrate (GTN) spray 400 micrograms – one or
two puffs as required. You dispense this item and speak with him and he tells you
that his GP thinks he has angina and has asked him to use the spray the next time he
gets any minor chest pain or tightness. You counsel Mr AG on the correct use of the
spray.
• Mr AG returns a few days later complaining of a headache following the use of the
spray. He is reluctant to use the spray again. He asks your advice on managing his
headache. He also smokes about five cigarettes a week and asks if he should now
stop.
•
• 1)What is angina?
• 2) What typical symptoms could a patient with angina present with?
• 4) What, if any, risk factors does Mr AG have for developing stable
angina?
• 5) What group of drugs does GTN spray belong to?
• 6) What are the side-effects of GTN spray?
• 8) Mr AG’s headache may be caused by his use of GTN spray. What
can you recommend to him to help manage his headache?
• 9)What advice would you give Mr AG in relation to his smoking?
Answers
1.
Angina, also known as angina pectoris, is chest pain or discomfort that occurs
when part of your heart muscle does not get enough oxygen-rich blood. It is a
common symptom of coronary heart disease, which develops when the arteries
of the heart become partially or totally blocked
2.
squeezing, pressure, heaviness, tightness or pain in the chest. It may feel like a
heavy weight lying on the chest.
3.
- Hyperlipidaemia - Lack of exercise
- Smoking - Poor diet
- Hypertension - Contraceptive pill
- Obesity - Heavy alcohol consumption
Stress Non-modifiable risk factors (those we cannot change) include:
age , gender, positive family history, diabetes mellitus, ethnicity.
4.
Age, Indian origin, sedentary job/possible lack of exercise, Smoking,
Gender – men are at increased risk.
5.
GTN is a nitrate. This class of drugs are potent vasodilators. At
therapeutic doses the main effect of nitrates is to act on vascular smooth
muscle to dilate the veins, thus reducing central venous pressure
(preload) and ventricular end diastolic volume. The overall effect is to
lower myocardial contraction, wallstress and oxygen demand, there by
relieving the angina. Nitrates also promote vasodilatation of the coronary
blood vessels.
6.
• Headaches (very common) Make sure you rest and drink plenty of fluids. ...
• Feeling dizzy, weak, tired or sleepy. Stop what you're doing and sit or lie
down until you feel better. ...
• Feeling sick (nausea) ...
• Red face (flushing)
7.
The patient should be instructed to:
- remove the cap and to hold the spray upright (vertically),
- prime the spray before using for the first time,
- spray one or two sprays under the tongue and close the mouth
immediately afterwards, and sit down and rest until the pain subsides.
8.
Mr AG can be advised to take paracetamol up to 4 g daily (i.e. one or
two500 mg tablets, every 4–6 hours; maximum eight tablets per 24 hours)
to relieve his headache. If the headache persists or is severe he should
arrange to see his GP to discuss his treatment.
9.
Anyone with angina who smokes should be advised to stop. Smokers have
ahigher incidence of ischaemic heart disease, and a greater risk of dying
from it.The greater the number of cigarettes smoke, the greater the risk.
Nicotine replacement therapy can be recommended as part of a smoking
cessation programme in people with angina.
Case 08; Farzana Yesmin
• A 23-year-old woman has a normal blood pressure (118/82mmHg) when reviewed at
8 weeks of pregnancy. In the 24th week of pregnancy, she is reviewed by her midwife
and found to have a blood pressure of 148/96mmHg. Urinalysis is normal.

• Questions:
• 1. What is the likely diagnosis?
• 2. What complications does the patient's high blood pressure place her at increased
risk of?
• 3. Should she receive drug treatment? If so, with which drug? If not, how should she
be managed?
Answers
1.
She may have gestation-induced hypertension or chronic hypertension that had
previously been masked by the fall in blood pressure that happens in early
pregnancy. N
2.
She is at increased risk of pre-eclampsia and intrauterine growth retardation.
3.
There are differences of opinion between specialists as to whether blood pressure
should be treated at this level during pregnancy. In favour of treatment is the
substantial rise over the earlier blood pressure recording. Some specialists would
not treat unless the blood pressure was >170/110 mmHg or other complications
were present. If she were treated, methyldopa would be a suitable choice. In any
event, she needs close monitoring of her blood pressure, urinalysis and fetal
growth.
Case 09 ;Jannatul lubna
A 52 year old African-American male have a history of obesity (BMI 30.5 Kg/m2), Dyslipidemia for 6
years, HTN for 10 years, Chronic kidney disease (stage 3) for 5 years, STEMI 6 months ago and also
GERD. Family history includes his father suffering MI at the age 50 and again at 60 years old and
his older brother of age 55 witn HTN and a history of one MI at the age of 48. His weight: 102.3 kg ,
pulse rate: 64 bpm, respiratory rate: 18 , temperature: 38.2 degree Celsius, Blood pressure: 136/84
mm Hg and LDL level is 121 mg/dl.
Current Medication-
Carvedilol 25 mg PO BID
Atorvastatin 80 mg PO once daily
Aspirin 81 mg PO once daily
Pantoprazole 40 mg PO daily
Lisinopril 40 mg PO daily
Chlorthalidone 25 mg PO daily
Acetaminophen 500 mg, one to two tablets PO PRN every 6 hours for pain
Garlic capsules
Questions-
• What additional information is needed to fully assess the patient’s
dyslipidemia?
• Create a list of patient’s drug therapy problems and prioritize them.
Include assessment of medication appropriateness, effectiveness and
safety.
• Create an individualized, patient-centered, team-based care plan to
optimize medication therapy for this patient's dyslipidemia and other
drug therapy problems.
Answers
1. Need full lipid profile to understand the type of dyslipidemia:
Total cholesterol (bound + nonbound) level <199 mg/dl
Total triglyceride level <150 mg/dl
Low density lipoprotein <100 mg/dl
Intermediate low density lipoprotein <100 mg/dl
High density lipoprotein <40 mg/dl
 Medication Effectiveness Safety
Carvedilol Not effective , blood pressure Safe
2) is uncontrolled
Atorvastatin Dyslipidemia is not controlled Safe

Clopidogrel Effective Not Safe( may cause

kidney problems if
taken with chlorthalidone)

Pantoprazole Effective Safe

Lisinopril Not effective , blood pressure Safe

is uncontrolled

Chlorthalidone Not effective , blood pressure Safe

is uncontrolled

Acetaminophen Effective Safe

Garlic capsules Effective Not safe

(may dangerously
lower blood pressure
and increase
bleeding with aspirin)
3.
Carvedilol 222225 mg po bid
Atorvastatin 40 mg po oid
Clopidogrel 75 mg po oid
Pantoprazole 20 mg po bid
Eplerenone 25 mg
Case 10; Sakib Hassan
Mr. Bhuiyan is 50 years old and 90 kg weight. For the last few days, he suffering
from chest pain and shortness of breath. So he is admitted to a local hospital. The
doctor gave him some tests and the test report shows that his TG & Chylomicron
levels are higher than the normal range and LDL, HDL, and VLDL are in the normal
range. He has a previous history of hypertension disease and he is also a chain
smoker.
1. What is your conclusion for this patient?
2. What are the risk factors for this disease?
3. What medicinal treatment you will provide for this patient?
Answers
1. The patient is suffering from type 1 dyslipidemia as his TG &
Chylomicron levels are higher than the normal range and LDL, HDL,
and VLDL are in the normal range.
2. Risk factors for dyslipidemia are: Type-1 diabetic, type-2 diabetic,
pregnancy, alcohol, smoke, chronic renal failure, renal transplantation,
cardiac transplantation, cholestasis, drugs such as anabolic steroids,
diuretics, amiodarone, and beta blockers.
3. The patient has type-1 dyslipidemia. So we can prescribe
Omega 3 fatty acid
Plant sterol
Exercise
 Case 11; Sufia Akter
Sakila Begum 60 year old housewife has a habit of having tobacco, about 6-7
year ago she had a attack of stroke with no paralysis. After 2-3 years she
developed DM and peripheral neuropathy, before the attack she only had
sleeping disturbances with no other disease. She is now taking medications are
Bizoran 5/20
Betacor 5
Viglimet 50/850
Novomix 30/70 (insulin)
Rocovas 5
Pegalin 50
Diamicron MR 30
Now she faces breath hard when walking or exercise, Diabetes is not being
controlled ( Fasting sugar around 8) and having recurrent urine infection
with fungal toenail.

QUESTIONS
1. What is your conclusion ?
2. What could be the reason behind of her Hypertension
3.Mention the drug –drug interaction and contraindications.
4. What will be your rationale drug of choice for her or your prescription?
5. Do you think is there any future complication with taking this drug and
your suggestions for the patient.
Answers
1. The patient is suffering from Metabolic disorder as she has
hypertension, DM type 2, high lipid profile
2. The cause of hypertension could be peripheral vascular resistance
as the patient has peripheral neuropathy where numbness, tingling,
burning sensation, muscle fatigue, cramps, pains are present which
also the symptoms of PVR disease.
3. Bisoprolol might not been prescribed to diabetic patient as it can
precipitate metabolic disorder more and increase panting problems
in old patients.
pregabalin with olmesartan barely can cause angioedema
4.
Insulin with high dose according with body weight
Ramipril 2.5 mg – oid - po
Empagliflozin 10 mg - oid - po
Rosuvastatin 10 mg - oid - po
Pregabalin 50 mg - oid - po
Aspirin 75 mg - oid - po

5. Long term use these drugs can impaired liver, kidney function
CASE12; Anamika Saha
Michael Thompson, 65 years old retired person is brought to the emergency department with severe chest pain that started
two hours ago while he was watching television. The pain is described as a crushing sensation in the chest, radiating to the
left arm and jaw, accompanied by shortness of breath, diaphoresis, nausea, and lightheadedness. The pain has been
persistent and unrelieved by sublingual nitroglycerin (three doses taken over 15 minutes). He has history of Hypertension,
Hyperlipidemia, Chronic Kidney Disease (Stage 3), Type 2 Diabetes Mellitus, Peripheral artery Disease. His brother died of a
myocardial infarction at age 55. His Current Medications: Metformin, Lisinopril, Atorvastatin, Aspirin, Clopidogrel, Amlodipine.

Physical examination history:

Blood pressure: 160/95mmHg mmHg
Heart Rate: 102 bpm
Respiratory Rate: 20 breaths per minute
Oxygen Saturation: 92% on room air
BMI: 32 kg/m²
Others findings: : Distended neck veins, S3 heart sound, bibasilar crackles on lung auscultation, mild
peripheral edema
Diagnostic Test results:
• Electrocardiogram (ECG): ST-segment depression in leads II, III, aVF, and V4-V6
• Troponin: Elevated at 1.5 ng/mL (normal <0.04 ng/mL)
• BNP (Brain or B type natriuretic peptide): Elevated at 350 pg/mL (normal <100 pg/mL)
• Creatinine: 2.0 mg/dL (baseline 1.6 mg/dL)
• Lipid Profile: LDL cholesterol 150 mg/dL (normal <100mg/dL), HDL cholesterol 30 mg/dL (normal >40mg/dL), triglycerides 210
mg/dL (normal < 150mg/dL).
• HbA1c: 8.2% (normal < 5.7%)
• Chest X-ray: Cardiomegaly and mild pulmonary edema

Questions:
1.What is the most likely diagnosis for Michael Thompson based on his symptoms and test results?
2.What immediate management steps should be taken in the emergency department for Michael’s condition?
3. Outline the long-term management strategies for Michael Thompson’s condition, including pharmacological and non-
pharmacological approaches.
4. Discuss the potential role and timing of invasive procedures, such as coronary angiography and revascularization, in the
management of Michael’s condition.
Answers
1.
Michael Thompson is likely suffering from Unstable Angina Pectoris. This is suggested
by his severe, persistent chest pain unrelieved by nitroglycerin.
2.
Immediate Management: Oxygen therapy
Antiplatelet therapy: Administer a loading dose of aspirin and clopidogrel to inhibit
platelet aggregation.
Anticoagulation: Initiate anticoagulation with heparin to prevent further thrombus
formation.
Nitroglycerin: Continue with intravenous nitroglycerin
Beta-blockers: Administer beta-blockers (e.g., metoprolol) if not contraindicated.
Morphine: Administer morphine for pain relief
3. Pharmacological Management: -
Antiplatelet agents: Continue dual antiplatelet therapy with aspirin and
clopidogrel.
Statins: Intensify lipid-lowering therapy with atorvastatin.
ACE inhibitors/ARBs: Continue lisinopril to manage hypertension and
provide cardiovascular protection.
Beta-blockers - Optimize diabetes management with metformin and
potentially other antidiabetic agents.
Non-Pharmacological Management: - Lifestyle modifications - Cardiac
rehabilitation
4.
Coronary Angiography: Perform coronary angiography urgently to
assess the extent and severity of coronary artery disease.
Revascularization: Depending on angiography findings,
revascularization with percutaneous coronary intervention (PCI) or
coronary artery bypass grafting (CABG) may be necessary. PCI is
preferred for single or double vessel disease amenable to stenting,
while CABG is considered for multivessel disease or left main coronary
artery disease.
Timing: Invasive procedures should be considered promptly, especially
if there is ongoing ischemia, hemodynamic instability, or high-risk
features on non-invasive testing.