CASE PRESENTATION ON SYSTEMIC HYPERTENSION IN SOAP FORMAT.pptx

Systemic hypertension, or high blood pressure, is a chronic condition characterized by elevated pressure in the arteries. Typically measured in millimeters of mercury (mmHg), it's diagnosed when readings consistently exceed 130/80 mmHg. This condition, often symptomless, increases the risk of serious health complications like heart disease, stroke, and kidney failure. Contributing factors include genetics, age, unhealthy lifestyle habits, obesity, and stress. Treatment involves lifestyle changes—such as a healthy diet, regular exercise, and stress management—and, if necessary, medications to lower blood pressure. Regular monitoring and management are crucial to mitigate risks and maintain overall health.

1. CASE PRASENTATION ON SYSTEMIC HYPERTENSION BY C.CHANDRU D.PHARM 2 ND YEAR

2. SUBJECTIVE NAME Mr.X AGE 60Yrs SEX MALE WEIGHT 56Kg HEIGHT 161cm BMI 21.6Kg/m 2 (Normal)

3. CURRENT PROBLEM : C/O Breathing Difficulty 3 Days, Dizziness 2 days MEDICAL HISRTORY : Coranary Artery Disease (CAD) Sustained Hypertension MEDICATION HISTORY :K/H/O Irregular Medication CAD & SHT – Tab Lasix-20mg,Tab.Enapril-2.5mg,Tab.Tenolol-50mg,Tab,Atorva-40mg,Tab.Isodril-5mg FAMILY HISTORY : Nil DRUG FOOD ALLERGY : Nil

4. OBJECTIVE VITALS SIGNS Normal Values DAY 1 10.12.2023 DAY 2 11.12.2023 DAY 3 12.12.2023 DAY 4 13.12.2023 TEMP (F) 97.8 F 98.4 98.6 98.4 98.5 BP (mm/Hg) 120/80mmHg 230/140  200/110  130/90  130/80  PR (/mm) 60-100(min) 96 92 78 76 RR (/mm) 12-16(min) 22  20  18  20 

5. LABARTARORY INVESTIGATION LABORATARY PARAMETERS OBSERVED VALUES NORMAL VALUES Hb 14.5g/dl Men : 14 to 18 g/dl Women: 12 to 16g/dl Tlc 6000 cells/Cu.mm 4000 to 11000/ml Plt 150000/ mcL 150,000 to 450,000/ml Rbc 4.4M/ mcL Men :4.35 to 5.65M Women: 3.92 to 5.13M

6. LIVER AND RENAL FUNCTION TEST TESTS OBSERVED VALUE NORMAL VALUE Bilirubin 0.8 mg/dl 0.2 to 1.3 mg/d Protein 6.8g/dl 6.0 to 8.3g /dl Urea 42mg/dl  5 to 20mg /dl Creatinine 1.3mg/dl 0.74 to 1.35 mg/dl RBG 102mg/dl Less than 140 mg/dl

7. ECG (ELECTROCARDIOGRAM ): Abnormal CHEST X RAY : Pulmonary Edema

8. ASSESSMENT A 60 year old male patient was admitted with breathing difficulty 3 days ,chest pain , with dizziness and he is a married , non vegetarian and smoker and family history nil . And the person physical examination shows the temperature is normal and the blood is increased day by day and the Hb , Tlc , Rbg values or normal and the urea level is high and because T he plasma urea was significantly related to both age and diastolic systolic blood pressure. And the ECG was abnormal and the X – ray results shows pulmonary edema.

9. DIAGNOSIS The patient results shows the patient blood pressure was high and the ECG is abnormal it shows the patient was diagnosed as a S ystemic H ypertension and the urea level is high because of systemic hypertension. And the x- ray results shows diagnosed as a Pulmonary E dema

10. PLAN Drug Treatment Chart S. NO BRAND NAME GENERIC NAME DOSE ROA FREQ Day 1 Day 2 Day 3 Day 4 1 Inj.Lasix Furosemide 20mg/2ml IV 1-0-1     2 Inj.Deriphyllin Theophylline 100mg/2ml IV 1-0-1     3 Inj.Ampilin Ampicillin 500mg/2ml IV 0-1-0     4 Tab.Lasix Furosemide 20mg Oral 1-1-0     5 Tab.Enapril Enalpril 2.5mg Oral 1-0-0    

11. S.NO BRAND NAME GENERIC NAME DOSE ROA FREQ DAY 1 DAY2 DAY 3 DAY 4 6 Tab.Tenolol Atenolol 50mg Oral 1-0-0     7 Tab.Ecosprin Aspirin 75mg Oral 0-1-0     8 Tab.Plavix Clopidogrel 75mg Oral 0-1-0     9 Tab.Atrova Atorvastin 40mg Oral 0-0-1     10 Tab.Aldactone Spironolactone 25mg Oral 1-0-0     11 Tab.Isodril Isorbide Di Nitrate 5mg Oral 1-1-1    

12. PHARMACIST INTERVENTION Furosemide and enalapril drug also having internal bleeding . Small wound self have a heavy blood so it is the reason for alternating aspirin Etofylline product labelling states that use with sympathetic blockers ( i.e , beta-blockers) should be avoided. I will advice to avoid smoking

13. PATIENT COUNSELLING DISEASE BASED: High blood pressure is a common condition that affects the body's arteries. It's also called hypertension. If you have high blood pressure, the force of the blood pushing against the artery walls is consistently too high. The heart has to work harder to pump blood . Pulmonary edema is a condition caused by too much fluid in the lungs. This fluid collects in the many air sacs in the lungs, making it difficult to breathe.

14. PATIENT COUNSELLING DRUG BASED: LASIX ( Furousemide ): Take potassium supplements or potassium-rich diet (banana, spinach, coconut water, etc.) as Lasix Tablet can decrease your potassium levels and lead to dehydration. You may be asked to get regular blood tests done to monitor your kidney function.

15. ENALAPRIL : Take this medicine in the dose and duration as advised by your doctor. Swallow it as a whole. Do not chew, crush or break it. Enalapril 2.5 Tablet may be taken with or without food, but it is better to take it at a fixed time. ATENOLOL : It may cause dizziness. If this happens to you, get up slowly when rising from a sitting or lying position. It can hide symptoms of low blood sugar if you are diabetic. Monitor your blood sugar levels regularly. Do not stop taking Aten 50 Tablet suddenly as it can cause your blood pressure to rise suddenly, thereby increasing the risk of heart attack and stroke .

16. Plavix For best results, take it at the same time every day. Plavix Tablet increases your risk of bleeding. Be careful while shaving, using sharp objects, or cutting fingernails or toenails. Do not discontinue using the medicine without consulting your doctor as this may increase your chances of having another heart attack or stroke. If you are scheduled to undergo a surgery or dental treatment, you may be asked to stop taking Plavix Tablet temporarily .

17. Atrova It may cause diarrhea, gas or an upset stomach. If any of these happen to you, take it with food. Inform your doctor if you experience fatigue, muscle weakness or muscle pain.  Your doctor may check your liver function before starting the treatment and regularly thereafter. Inform your doctor if you notice signs of liver problems such as stomach pains, unusually dark urine or yellowing of skin or eyes.

18. Diet based patient counseling FOOD : Consume low sodium and trans free foods and eat rich nutrients and fresh fruits and berries avoid alcohol consuming. LIFE STYLE CHANGES : Do normal exercise and workout. Strictly avoid alcohol ,smoking and other drugs. Don’t be a emotion do medication.