A 47-year old female patient was admitted to the hospital with complaints of chest pain for one week, shortness of breath, and dizziness. Her medical history includes diabetes for 5 years and hypertension for 5 years. On examination, her blood pressure was elevated and blood sugar levels were high. An echocardiogram showed AV ischemia and normal left ventricular function. She was assessed as having diabetes, hypertension, and AV ischemia. The treatment plan is to control her blood sugar, blood pressure, improve medication adherence and lifestyle changes.

1. G.MAHESH
PHARM.DVI YR
22-01-2014

2. PATIENT PROFORMA
 NAME:-Mrs.X
 AGE:-47 yrs
 SEX:-female
 WEIGHT:-60
 HEIGHT:-160 cms

3. S-subject
 A 47 years old female pt admitted in hospital on 5-2-14 with
C/O chest pain * 1 week, retrosternal radiating to left arm ,
H/O breathlessness one week grade II & III dyspnoea,
giddiness. A past medical history shows known case of DM
* 5 years HTN *5 years , pt is post menopausal. A past
medication history tablet Glibenclamide 5 mg ½-0 – ½
,tab. Metformin 500mg ½ -0-1/2, tab.Coversyl 4mg 1-0-1

4. O-objective
 O/E:- Pt is C/O/A, hydration – fair, CVS/RS-NAD,
P/A-Soft , CNS-NFND, P-/I-/C-/C+/L-/E-, BP-140/90
mmHg on 5-2-14, 130/80 mmHg on 6-2, 140/80 on 7-2-
14. Temp-N, PR-82b/m,RR-22b/m. BUN 25 gm/dl,RBS-
312g/dl, PPBS-228g/dl,urine+, sugar++, Hb-9g/dl,
echo- AV Ischemia, normal LV Systole function

5. A-assessment
 Based on the above objective such as FBS,PPBS,BP&
ECHO reports it assessed that pt is diagnosed to have
DM,HTN,AV ISCHEMIA

6. P-plan
 The goal of the therapy is to maintain
Normal blood sugar levels
Control BP
Medication adherence
Better life style compliance

7. S.no Drug name Dose ROA Frequency
1 T. COVERSYL 4mg P/O 1-0-1
2 T.ATEN 50mg P/O ½-0-1/2
3 T.ATORVA 10mg P/O 0-0-1
4 T.ALPRAX 0.5mg P/O 0-0-1
5 T.RANTAC 150mg P/O 1-0-1
6 T.MVT 1tab P/O 1-0-0
7 T.ISDN 5mg P/O 1-1-1
8 T.ASPIRIN 150mg P/O 0-1-0
9 T.METFORMIN 500mg P/O 2-0-2
10 T.VIDAGLIPTIN 50mg P/O 0-1-0

8. Patient counselling
On diet:-
 Diet & physical activity are critically important in HbA1c,
BP& Cholesterol of Type 2 DM
 People taking long acting insulin and oral medications
should have food consistently eating at same time everyday
to decrease blood sugar levels
 If meal is skipped or delayed on those regimens you are at
risk for developing blood sugar level.

9.  Weight loss- losing even a small amount of weight 5-
10% of TBW can help the body to produce and use
insulin more effectively.
 Recommended calorie intake – to lose 1-2 pounds
substract 500-10000 calories from total no. of calorie
need to maintain weight.
 Avoid weight gain as blood glucose control improve it
maybe necessary to decrease your calorie intake by
250-300 calorie / day to avoid weight gain.

10.  Exercise regularly can help to lose weight and keep it
off.
 MEDICINE:-
 COVERSYL:- Perindopril given for HTN & congestive
cardiac failure.
 For HTN – 4mg OD, ADR’s:- Headache Cough,
Flushing, Oedema.
 ATEN (ATENOLOL):- Given for HTN & MI
Dosage for HTN:- 12.5-25mg OD / 50mg OD. Special
precautions seen in Renal failure & DM.

11.  ALPRAX(ALPRAZOLAM):-To control anxiety 0.25mg-
0.5mg bid/tid. Over dose causes:- Gastric Lavage .
 METFORMIN:-Initial dose:- 250mg BD . Increase
gradually at 2 weeks. Max 3mg/day.
 ASPIRIN(ACETYLSALICYLIC ACID):-Given for anti
inflammatory, amti pyretic, osteo arthritis, myalgia,
dental pain.
 For anti platelet effect:- 75-150mg/day. ADR’s:-
Indigestion, breathlessness.