UNIVERSITATEA DE STAT DE MEDICINA SI FARMACIE

“NICOLAE TESTEMITANU”

DEPARTMENT OF CLINICAL PHARMACOLOGY

Head of department: Member of the Academy of Sciences of Moldova,
d.h.ş.m., prof. univer.,

Ghicavîi Victor

The group leader: d.ş.m., conf. univer.,

Tarabih Moataz

Group 1543

Date :- 20.03.2014

1 ANAMNEZA:

General :-

• Name: Creliciuc Maria

• Age: 64ani (15/04/1949)

• Location: Kishinau

• Date of admission: 04/12/2012

• Diagnosis on admission: Angina Pectoralis agrevation , arrythmia Ascites .

• Diagnosis: Angina Pectoralis agregation ,arrythmia ,ascites, valvulopathies, heart

insufficincy , hypertension grade 3 , chronic pancreatitis , pylonephretis bileteral ,
anemia grade 3 .
Complaint:-

The patient had mixed dyspnea at minimum physical effort , chest pain at
minimum physical effort , heart palpitation , peripherial Edema .

Current disease history (anamnesis morbidity)

It is considered ill for about more than 10 years ago , she had :-

Cardiovascular disease at 1991

Reumatic fever also at 1991

Hypertension for 10 years ago and the maximum was (200/110)

Patient's life history (anamnesis vitae):

Home treatment :- Digoxin 0.25 one tab per day , sperenolactone , furasemide ,
captopril 25 mg sublingual in crisis , asperin 100mg/d .

The patient grew and developed according to ages.

Medical history:- infectious diseases such as tuberculosis, syphilis, toxoplasmosis,

rugeola hepatitis patients deny.

Allergy history: - The patient has allergic reactions to drugs anti histamine h1 just.

History of social environment: - Currently not working

Factors in the external environment as: cold, damp, noise industrial environment
on a long term was not subjected.
2 Physical examination SOMATICO-visceral

The general condition of the patient :-

General Conditions: - medium severity

Position:-active

Constitutional status: - normostenic

Nutritional status: satisfactory.

h = 175 cm. Signs of acromegaly, macro, or

microcephaly - not present.

Skin and mucous membranes visible :- subectirical , Edema .

Lymph nodes: - not palpate.

Thyroid Status: - not palpate.

Muscles Status: - normal development (according to age and sex), anthropometric

and contralateral symmetrical.

Osteo-articular system: normal development - without deformation.

Manifestations of type arthritis, arthrosis, stiffness and fracture - no.

Respiratory system:

Breath: diminshid mostly in the right

- Spontaneous vesicular

- Frequency = 20 breaths / minute.

Percussion lungs:

• Comparative Percussion: - striker symmetrical regions attests clear sound lung. It

followed a symmetrical.
Lung auscultation: - auscultation decrease in the sound specialy in the right side .

Cardiovascular:

Auscultation:

- rhythmic heart sounds are clear.

- Cardiac and extracardiac murmurs missing.
- systolic sound in all points of ascultation .

On auscultation of the carotid arteries does not charge any blast.

Pulse - palpated on both radial arteries is symmetrical, rhythmic frequency is

115 / min,

blood pressure: both arms = 130/80 mm Hg.

- Smoking: deny.

-Physical Inactivity: deny.

-Drinking alcohol in excess: deny.

Digestive:

Mouth, tongue clean.

Abdomen slender painless on palpation and pain in the epigastric and right side of
the abdomen .

stool: tenesmus, false pulse and diarrhea - do not complain.

Liver: -increase in size 6.8 cm and painful.

Spleen: - not palpates.

Urogenital:

Palpation: the bimanual palpation of the kidneys missing tactile sensation would

detect change in position of the kidneys (not palpate).

Bladder palpation is not evidence of pathological changes (retention of urine).

Percussion: - kidney no percution .

Adequate diuresis .

The Endocrine System

complain of endocrine system not present.

PLAN laboratory investigations:

a blood count.

b general analysis of urine.

C. Biochemical analysis of blood.

d electrocardiogram.

CT or ultrasound for abdomen and ECHOCARDIOGRAPH .

The result of laboratory investigations:

A.blood count

Hb – 10.2g / l

RBC - 4.74 ∙ 10*6 / l

WBC: 4.3 ∙ 10*3 / l

Lymphocytes – 1.3*10*3

Monocytes – 0.4 *10*3

HCT – 33.7%

MCV – 71.0 Fl

PLT- 335*10*3 /ul

B. Biochemical analysis of blood:

The total protein: 71.9 g / l;

Urea – 13.73 mmol / l

General Bilirubin – 106.2μmol / l

ALAT- 11.4 U / l;

ASAT- 18.8 U / L;

Glucose -5.64 mmol / l

C. Electrocardiogram

Sinus rhythm

frequency of 95 b / min.

Electrical axis of the heart through.

 TREATMENT

B. Medications:

Sol. Diazepam -2 ml I/M

Sol. glucose 200ml-5% + Sol Kclor 4%-30ml

Sol. Furasamid 6ml IV

Sol. Strophantin 0.025%-1ml IV

Sol. Vit B6-2 ml i/m

Sol. Vit c-5 ml-5% i/m

Heparin 5000 IU 4 times a day SC

Ramipril 10mg half of tab in evening

Magnisium sulphate 25%-5ml IV

Diagnosis :-

Angina Pectoralis agregation

arrythmia ,ascites

valvulopathies

heart insufficincy

hypertension grade 3

chronic pancreatitis

pylonephretis bileteral

anemia grade 3 .
Regime administered drugs :-

04. 05. 06. 07. 08. 09. 10. 11.

Sol. Diazepam -2 ml I/M + + + + + + + +

Sol. glucose 200ml-5% - + + + + + - -

Sol Kclor 4%-30ml + + + + + - -

Sol. Furasamid 6ml IV + + + + + + + +

Sol. Vit.B6 2ml i/m + + + + + + + +

Sol. Strophantin 0.025%-1ml + + + + + + + +

Sol. Vit c-5 ml-5% i/m + + + + + + + +

Heparin 5000 IU + + + + - - - -

Ramipril 10mg + + + + + + + +

Magnisium sulphate 25%-5ml + + + + + + + +

Preparations used in the treatment of stationary

1- Glocuse 200ml – 5%

Dextrose is a form of glucose (sugar). Dextrose 5% in water is injected into a vein

through an IV to replace lost fluids and provide carbohydrates to the body.
Dextrose 5% in water is used to treat low blood sugar (hypoglycemia), insulin
shock, or dehydration (fluid loss). Dextrose 5% in water is also given for
nutritional support to patients who are unable to eat because of illness, injury, or
other medical condition.
Dextrose 5% in water is sometimes used as a diluent (liquid) for preparing
injectable medication in an IV bag. A diluent provides a large amount of fluid in
which to dilute a small amount of medicine. The diluent helps carry the medicine
into your bloodstream through the IV. This helps your caregivers inject the
medicine slowly and more safely into your body.
Dextrose 5% in water may also be used for purposes not listed in this medication
guide.

What is the most important information I should know about dextrose 5% in

water?

You should not use this medication if you are allergic to dextrose.
Before using dextrose 5% in water, tell your doctor if you have diabetes, breathing
problems, an electrolyte imbalance, kidney or liver disease, a food or drug allergy,
or if you receive regular blood transfusions.

Do not mix dextrose 5% in water with any medication that has not been prescribed
by your doctor. If you are using the injections at home, be sure you understand
how to properly mix and store your medicine.
Tell your caregivers if you feel any burning, pain, or swelling around the IV needle
when dextrose 5% in water is injected.
Stop using dextrose 5% in water and call your doctor at once if you have a fever,
cough, wheezing, increased thirst or urination, confusion, hallucinations, extreme
thirst, muscle weakness, weak or shallow breathing, fainting, or severe irritation or
signs of infection around the IV needle.

What should I discuss with my healthcare provider before using dextrose 5%

in water?

You should not use this medication if you are allergic to dextrose.
To make sure you can safely use dextrose 5% in water, tell your doctor if you have
any of these other conditions:
 diabetes;
 breathing problems;
 an electrolyte imbalance (such as low levels of potassium in your blood);
 kidney or liver disease;
 any allergy to foods or medicines; or
 if you receive regular blood transfusions.
FDA pregnancy category C. It is not known whether dextrose 5% in water will
harm an unborn baby. Tell your doctor if you are pregnant or plan to become
pregnant while using this medication.
It is not known whether dextrose 5% in water passes into breast milk or if it could
harm a nursing baby. Do not use this medication without telling your doctor if you
are breast-feeding a baby.

How is dextrose 5% in water given?

Dextrose 5% in water is injected into a vein through an IV. You may be shown
how to use an IV at home. Do not self-inject this medicine if you do not fully
understand how to give the injection and properly dispose of used needles, IV
tubing, and other items used to inject the medicine.
Before using dextrose 5% in water, check the solution container to make sure there
are no leaks in it. Use only the needle type and size recommended by your doctor
or caregivers.
Dextrose 5% in water should be clear and colorless. Do not use the medication if it
has changed colors or has particles in it, or if the seal on the IV bag is broken. Call
your doctor for a new prescription.
You may need to mix dextrose 5% in water with another medication in an IV bag
before using it. Do not mix dextrose 5% in water with any medication that has not
been prescribed by your doctor. If you are using the injections at home, be sure you
understand how to properly mix and store your medicine.
Call your doctor or tell your caregivers if your catheter, needle, or IV tubing
becomes blocked or if the solution is not flowing normally.
If you receive this medication in a hospital or clinic setting your breathing, blood
pressure, oxygen levels, and other vital signs will be watched closely. Your blood
sugar may also need to be tested often during treatment. If you use the medicine at
home, visit your doctor regularly. Do not miss any follow up visits to your doctor
for blood or urine tests.
Tell your caregivers if you feel any burning, pain, or swelling around the IV needle
when dextrose 5% in water is injected.
Use a disposable needle only once. Throw away used needles in a puncture-proof
container (ask your pharmacist where you can get one and how to dispose of it).
Keep this container out of the reach of children and pets.
Call your doctor if your symptoms do not improve, or if they get worse while using
dextrose 5% in water.
Store at room temperature away from moisture and heat. Do not freeze.

Dextrose 5% in water side effects

Get emergency medical help if you have any of these signs of an allergic
reaction: hives; difficult breathing; swelling of your face, lips, tongue, or throat.
serious side effect such as:
 severe burning, pain, or swelling around the IV needle;
 warmth, redness, oozing, or bleeding where the IV was placed;
 fever, ongoing cough;
 high blood sugar (increased thirst, increased urination, hunger, dry mouth,
fruity breath odor, drowsiness, dry skin, blurred vision, weight loss);
 headache, trouble concentrating, memory problems, weakness, feeling
unsteady, hallucinations, fainting, seizure, shallow breathing or breathing that
stops;
 low potassium (confusion, uneven heart rate, extreme thirst, increased
urination, leg discomfort, muscle weakness or limp feeling); or
 anxiety, sweating, pale skin, severe shortness of breath, wheezing, pain, fast or
uneven heart rate.
Less serious side effects may include:
 mild irritation around the IV needle;
 upset stomach; or
 swelling in your hands or feet.

2- Furosemide solution 6ml

is used for:

Treating fluid buildup and swelling caused by certain conditions (eg, congestive
heart failure, liver cirrhosis, kidney problems). It is also used alone or with other
medicines to treat high blood pressure. It may also be used for other conditions as
determined by your doctor.
Furosemide solution is a loop diuretic. It works by helping the kidneys to remove
fluid from the body.

Do NOT use furosemide solution if:

 you are allergic to any ingredient in furosemide solution

 you are unable to urinate
 you are taking chloral hydrate, ethacrynic acid, disulfiram, or metronidazole
Contact your doctor or health care provider right away if any of these apply to you.

Before using furosemide solution:

Some medical conditions may interact with furosemide solution. Tell your doctor
or pharmacist if you have any medical conditions, especially if any of the
following apply to you:
 if you are pregnant, planning to become pregnant, or are breast-feeding
 if you are taking any prescription or nonprescription medicine, herbal
preparation, or dietary supplement
 if you have allergies to medicines, foods, or other substances
 if you have had a severe allergic reaction (eg, severe rash, hives, difficulty
breathing, dizziness) to sulfonamide (sulfa) medicines (eg, sulfamethoxazole)
 if you have fluid in your abdomen (ascites), hearing problems, liver problems,
diabetes, high blood sugar, bladder or urinary problems, prostate problems,
kidney problems, lupus, gout, abnormal blood electrolyte (eg, potassium,
sodium) levels, high blood uric acid levels, low blood protein levels, or high
blood cholesterol or triglyceride levels
 if you are dehydrated, have low blood volume, or are on a low-salt (sodium)
diet
 if you eat large amounts of licorice, drink alcohol, or use laxatives on a regular
basis
MEDICINES MAY INTERACT with furosemide solution. Tell your health care
provider if you are taking any other medicines, especially any of the following:
 Corticosteroids (eg, prednisone) or corticotropin (ACTH) because the risk of
low blood potassium levels may be increased
 Barbiturates (eg, phenobarbital) or narcotics (eg, codeine) because the risk of
dizziness when standing may be increased
 Aminoglycoside antibiotics (eg, gentamicin), cisplatin, or ethacrynic acid
because the risk of hearing problems may be increased
 Angiotensin-converting enzyme (ACE) inhibitors (eg, captopril) or angiotensin
receptor blockers (ARBs) (eg, losartan) because the risk of low blood pressure
and serious kidney problems may be increased
 Cyclosporine because the risk of developing gout may be increased
 Chloral hydrate because side effects, such as excessive sweating, rapid
heartbeat, and changes in blood pressure, may occur
 Certain cephalosporins (eg, cefotetan), disulfiram, furazolidone, metronidazole,
or sulfonylureas (eg, glipizide) because side effects, such as flushing, headache,
fast or irregular heartbeat, trouble breathing, nausea, or vomiting, may occur
 Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen, indomethacin,
naproxen) or phenytoin because they may decrease furosemide solution's
effectiveness
 Cephalosporin antibiotics (eg, cephalexin), digoxin, lithium, medicines for high
blood pressure, methotrexate, or salicylates (eg, aspirin) because the risk of
their side effects may be increased by furosemide solution
 Medicines that may harm the kidney (eg, amphotericin B, tacrolimus,
vancomycin) because the risk of kidney side effects may be increased. Ask
your doctor if you are unsure if any of your medicines might harm the kidney
This may not be a complete list of all interactions that may occur. Ask your health
care provider if furosemide solution may interact with other medicines that you
take. Check with your health care provider before you start, stop, or change the
dose of any medicine.

Possible side effects of furosemide solution:

All medicines may cause side effects, but many people have no, or minor, side
effects. Check with your doctor if any of these most COMMON side effects persist
or become bothersome:
Constipation; diarrhea; dizziness; light-headedness.
Seek medical attention right away if any of these SEVERE side effects occur:
Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the
chest; swelling of the mouth, face, lips, or tongue); blurred vision; calf or leg pain,
swelling, redness, or tenderness; chest pain; coughing up blood; fainting; fever,
chills, or sore throat; numbness, burning, or tingling sensation; red, swollen,
blistered, or peeling skin; ringing in the ears or other hearing problems (eg, hearing
loss); severe or persistent dizziness; severe stomach or back pain (with or without
nausea or vomiting); shortness of breath; symptoms of dehydration or electrolyte
problems (eg, very dry mouth; unusual thirst; decreased urination; mental or mood
changes, such as confusion; fast or irregular heartbeat; muscle aches, cramps, pain,
spasms, or weakness; drowsiness; seizures; sluggishness; unusual restlessness, loss
of appetite, or weakness; nausea and vomiting); symptoms of high blood sugar (eg,
increased thirst, hunger, or urination; confusion; drowsiness); symptoms of liver
problems (eg, dark urine, loss of appetite, pale stools, severe stomach pain,
yellowing of the skin or eyes); unusual bleeding or bruising; unusual tiredness or
weakness; vein inflammation; yellow vision.
 3- STROPHANTHIN 0.025%-1ml

COMPOSITION:
Strophanthin G 0.25 mg/1 ml in one ampoule
Strophanthin K 0.25 mg/1 ml in one ampoule

ACTION:
Cardiac glucoside with cardiotonic action: enhances systolic contractions,
while reducing their duration; slows down the cardiac rhythm and prolongs the
diastole which improves the blood flow to the ventricles; it slightly reduces the
excitability of the cardiac conduction system; increases diuresis which is
associated mainly with the general improvement of blood circulation. It has a
highly effective, fast and short-term action. After intravenous administration
the effect is manifested 5-10 min later, reaching its maximum after 1-1 1/2 h. It
does not cumulate. The cardiotonic effect of strophanthin G and its toxic action
are almost 1.5 times stronger than those of strophanthin K.

INDICATIONS:
Acute cardiovascular insufficiency, left venticular insufficiency predominantly
(cardiac asthma, pulmonary edema, acute myocardial infarction); severe form
of chronic cardiac insufficiency; acute infectious diseases; paroxymal
tachycardia.

CONTRAINDICATIONS:
Pronounced, grave organic changes in the heart and vessels, acute myocarditis
and endocarditis, tendency to thromboembolic processes, bigeminy, advanced
cases of cardiosclerosis, grave renal insufficiency.

SIDE EFFECTS:
In overdosage (abrupt bradycardia, extrasystoles, bigemiy) - the treatment is
discontinued or the doses are reduced and the interval between the individual
injections is prolonged.

PRECAUTIONS:
After treatment with digitalis drugs, due to their cumulation, injection of
strophanthin should start after an interval of several days and with a reduced
first dose.
DRUG INTERCATIONS:
Cardiac glucosides interact with an extremely large number of drugs. Some of
the more important interactions are: strophanthin toxicity is enhanced
bymagnesium sulfate, all 'bitter' salts, amphotericin, biz acodal, carbenoxolon,
ACTH, mineral oils, glucocorticoids, insulin, laxative saluretic agents;
strophanthin action is enhanced by acetazolamide, quinidine, dehydrocholic
acid, diasoxide, diclophenamine, himecromon; its action is diminished by
coumarin anticoagulants, thyroxine, potassium agents, potassium retaining
diuretics, etc.

DOSAGE AND ADMINISTRATION:

Strophanthin G
It is intravenously administered in a single mean daily dose of 0.25 mg, diluted
with 10 ml physiologic salt solution or 10-20 % glucose solution, injected very
slowly (within 2-3 min). the first injections are with a lower dose, cautiously -
for testing the individual sensitivity to the drug (particularly after digitalis
treatment) the duration of the treatment course is determined by the therapeutic
response and by the indications for treatment of the concrete patient.
Strophanthin K
It is intravenously injected in a single daily dose of 0.25-0.5 mg, diluted with
10-20 ml 10-20 % glucose solution or physiologic salt solution in the same
quantity. When intravenous injection is impossible, intramuscular injections
can be prescribed in a dose increased about 1.5 times. In case of painful site of
injection, it can be infiltrated with 5 ml of 2 % novocain solution (Caution:
hypersensitivity to novocain).

MEDICINAL FORM AND PACKAGE:

Strophanthin G
Packages with 10 and 50 ampoules of 0.25 mg/ 1 ml (0.025 %).
Strophanthin K
Packages with 10 and 50 ampoules of 0.25 mg/1 ml (0.025 %).

STORAGE:
At moderate temperature (15-30° C).

EXPIRY:
2 (two) years.
 4- Sol. Vit B6-2 ml i/m :-

therapeutic action

Vitamin B6 (pyridoxine ) is part of group B vitamins , found in yeast and in

certain vegetables. It plays an important role in the metabolism of amino acids and
fats . Therefore , pyridoxine plays an active role in tissue changes , especially in
terms of liver tissue , nervous system, skin and blood-forming organs .

indications

Aplastic anemia and erythroblastic , hypochromic anemia resistant to treatment

with iron toxicity or drug granulopenie origin , diseases of the central nervous
system etiology of arteriosclerotic or encephalitis , preventive and curative
treatment of brain disorders or drug toxic home , especially hydrazine cramps ,
hipertoniemusculara , myopathy, acrodinie , vomiting , especially pregnant or
postroentgenterapice postanestezice , tremors idiopathic senile or toxic origin ,
Parkinson's disease , arteriosclerotic parkinsonism , acute alcoholism , skin
conditions like dermatitis seborrheic , acne, dermatitis postroentgeniene light ;
arteriosclerotic disease various areas .

Dosage and administration

Adults dose of 50-250 mg daily for 15-20 days , administered orally or injection (
intramuscular , intravenous ) .

Children: 20-50 mg doses after age and severity of the case .

contraindications

Vitamin B6 is contraindicated in case of treatment with levodopa, a

antiparhinsonian .

adverse Reactions

2-10 g daily doses of vitamin B6 can trigger neurological disorders.

Excess vitamin B6 is likely to cause anxiety and living too vivid nocturnal dreams.

It is not recommended level exceeding 500 mg vitamin B6 .

5- Vitamin C 5%-5ml

is used for:

Treating and preventing low levels of vitamin C. It may also be used for other
conditions as determined by your doctor.
Ascorbic acid solution is a vitamin. It works by supplementing vitamin C, which is
used in many functions in the body.

Do NOT use if:

 you are allergic to any ingredient in ascorbic acid solution

Contact your doctor or health care provider right away if any of these apply to you.

Before using:

Some medical conditions may interact with ascorbic acid solution. Tell your doctor
or pharmacist if you have any medical conditions, especially if any of the
following apply to you:
 if you are pregnant, planning to become pregnant, or are breast-feeding
 if you are taking any prescription or nonprescription medicine, herbal
preparation, or dietary supplement
 if you have allergies to medicines, foods, or other substances
 if you have diabetes, glucose-6-phosphate dehydrogenase deficiency, a high
iron level in the blood, anemia (eg, sickle cell, sideroblastic, thalassemia), or
kidney stones

MEDICINES MAY INTERACT with ascorbic acid solution. Tell your health
care provider if you are taking any other medicines, especially any of the
following:
 Anticoagulants (eg, warfarin) because side effects may be increased by ascorbic
acid solution
This may not be a complete list of all interactions that may occur. Ask your health
care provider if ascorbic acid solution may interact with other medicines that you
take. Check with your health care provider before you start, stop, or change the
dose of any medicine.

Important safety information:

 Do not take large doses of vitamins (megadoses or megavitamin therapy) while

taking ascorbic acid solution unless directed to by your doctor.
 Ascorbic acid solution may cause incorrect results with some in-home
cholesterol test kits. Check with your doctor or pharmacist if you are taking
ascorbic acid solution and need to check your cholesterol at home.
 Diabetes patients - Ascorbic acid solution may cause incorrect test results with
some urine glucose tests. Check with your doctor before you adjust the dose of
your diabetes medicine or change your diet.
 Ascorbic acid solution may cause incorrect test results with kits used to check
for blood in the stool. Check with your doctor if you are taking ascorbic acid
solution when using the test kit.
 PREGNANCY and BREAST-FEEDING: If you become pregnant while taking
ascorbic acid solution, discuss with your doctor the benefits and risks of using
 ascorbic acid solution during pregnancy. Ascorbic acid solution is excreted in
breast milk. If you are or will be breast-feeding while you are using ascorbic
acid solution, check with your doctor or pharmacist to discuss the risks to your
baby.

Possible side effects:

All medicines may cause side effects, but many people have no, or minor, side
effects. Check with your doctor if any of these most COMMON side effects persist
or become bothersome:
Diarrhea; nausea; upset stomach; vomiting.
Seek medical attention right away if any of these SEVERE side effects occur:
Severe allergic reactions (rash; hives; difficulty breathing; tightness in the chest;
swelling of the mouth, face, lips, or tongue); kidney stones (eg, abdominal
pain/back pain, painful urination).
This is not a complete list of all side effects that may occur. If you have questions
about side effects, contact your health care provider. Call your doctor for medical
advice about side effects.

6- Heparin 5000 IU :-

Heparin (from Ancient Greek ηπαρ (hepar), liver), also known as unfractionated
heparin, a highly sulfated glycosaminoglycan, is widely used as an
injectable anticoagulant, and has the highest negative charge density of any
known biological molecule.[3] It can also be used to form an inner anticoagulant
surface on various experimental and medical devices such as test tubes and renal
dialysis machines.
Although it is used principally in medicine for anticoagulation, its true
physiological role in the body remains unclear, because blood anticoagulation is
achieved mostly by heparan sulfate proteoglycans derived
from endothelial cells.[4] Heparin is usually stored within the secretory granules
of mast cells and released only into the vasculature at sites of tissue injury. It has
been proposed that, rather than anticoagulation, the main purpose of heparin is
defense at such sites against invading bacteria and other foreign materials.[5] In
addition, it is conserved across a number of widely different species, including
some invertebrates that do not have a similar blood coagulation system.

Medical use
Heparin is a naturally occurring anticoagulant produced by basophils and mast
cells.[12] Heparin acts as an anticoagulant, preventing the formation of clots and
extension of existing clots within the blood. While heparin does not break down
clots that have already formed (unlike tissue plasminogen activator), it allows the
body's natural clot lysis mechanisms to work normally to break down clots that
have formed. Heparin is generally used for anticoagulation for the following
conditions

 Acute coronary syndrome, e.g., NSTEMI

 Atrial fibrillation
 Deep-vein thrombosis and pulmonary embolism
 Cardiopulmonary bypass for heart surgery
 ECMO circuit for extracorporeal life support
 Hemofiltration
 Indwelling central or peripheral venous catheters

Mechanism of action
Heparin and its low-molecular-weight derivatives
(e.g., enoxaparin, dalteparin, tinzaparin) are effective at preventing deep vein
thromboses and pulmonary emboli in patients at risk,[13][14] but no evidence
indicates any one is more effective than the other in preventing
mortality.[15] Heparin binds to the enzyme inhibitor antithrombin III (AT), causing
a conformational change that results in its activation through an increase in the
flexibility of its reactive site loop.[16] The activated AT then
inactivatesthrombin and other proteases involved in blood clotting, most
notably factor Xa. The rate of inactivation of these proteases by AT can increase
by up to 1000-fold due to the binding of heparin.[17]
AT binds to a specific pentasaccharide sulfation sequence contained within the
heparin polymer:
GlcNAc/NS(6S)-GlcA-GlcNS(3S,6S)-IdoA(2S)-GlcNS(6S)
The conformational change in AT on heparin-binding mediates its inhibition of
factor Xa. For thrombin inhibition, however, thrombin must also bind to the
heparin polymer at a site proximal to the pentasaccharide. The highly negative
charge density of heparin contributes to its very strong electrostatic interaction
with thrombin.[3] The formation of a ternary complex between AT, thrombin, and
heparin results in the inactivation of thrombin. For this reason, heparin's activity
against thrombin is size-dependent, with the ternary complex requiring at least 18
saccharide units for efficient formation.[18] In contrast, antifactor Xa activity
requires only the pentasaccharide binding site
.
This size difference has led to the development of low-molecular-weight
heparins (LMWHs) and, more recently, to fondaparinux as pharmaceutical
anticoagulants. LMWHs and fondaparinux target antifactor Xa activity rather than
antithrombin activity, with the aim of facilitating a more subtle regulation of
coagulation and an improved therapeutic index. The chemical structure of
fondaparinux is shown above. It is a synthetic pentasaccharide, whose chemical
structure is almost identical to the AT binding pentasaccharide sequence that can
be found within polymeric heparin and heparan sulfate.
With LMWH and fondaparinux, the risk of osteoporosis and heparin-induced
thrombocytopenia (HIT) is reduced. Monitoring of the activated partial
thromboplastin time is also not required and does not reflect the anticoagulant
effect, as APTT is insensitive to alterations in factor Xa.
Danaparoid, a mixture of heparan sulfate, dermatan sulfate, and chondroitin
sulfate can be used as an anticoagulant in patients having developed HIT. Because
danaparoid does not contain heparin or heparin fragments, cross-reactivity of
danaparoid with heparin-induced antibodies is reported as less than 10%.[19]
The effects of heparin are measured in the lab by the partial thromboplastin time
(aPTT), one of the measures of the time it takes the blood plasma to clot. Partial
thromboplastin time should not be confused with prothrombin time, or PT, which
measures blood clotting time through a different pathway of the coagulation
cascade.
Administration :-
Heparin is given parenterally because it is not absorbed from the gut, due to its
high negative charge and large size. It can be injected intravenously or
subcutaneously (under the skin); intramuscular injections (into muscle) are avoided
because of the potential for forming hematomas. Because of its short biologic half-
life of about one hour, heparin must be given frequently or as a
continuous infusion. Unfractionated heparin has a half-life of about one to two
hours after infusion, [20] whereas LMWH has a half-life of four to five
hours.[21] The use of LMWH has allowed once-daily dosing, thus not requiring a
continuous infusion of the drug. If long-term anticoagulation is required, heparin is
often used only to commence anticoagulation therapy until an oral anticoagulant
e.g. warfarin takes effect.
Details of administration are available in clinical practice guidelines by
the American College of Chest Physicians:[22]

 Non-weight-based heparin dose adjustment

 Weight-based-heparin dose adjustment

Production
Pharmaceutical-grade heparin is derived from mucosal tissues of slaughtered meat
animals such as porcine (pig) intestines or bovine (cattle) lungs.[23] Advances to
produce heparin synthetically have been made in 2003 and 2008.[24]
Adverse reactions
A serious side-effect of heparin is heparin-induced thrombocytopenia (HIT),
caused by an immunological reaction that makes platelets a target of
immunological response, resulting in the degradation of platelets, which causes
thrombocytopenia. This condition is usually reversed on discontinuation, and in
general can be avoided with the use of synthetic heparins. Also, a benign form of
thrombocytopenia is associated with early heparin use, which resolves without
stopping heparin.
Two nonhemorrhagic side-effects of heparin treatment are known. The first is
elevation of serum aminotransferase levels, which has been reported in as many as
80% of patients receiving heparin. This abnormality is not associated with liver
dysfunction, and it disappears after the drug is discontinued. The other
complication is hyperkalemia, which occurs in 5 to 10% of patients receiving
heparin, and is the result of heparin-induced aldosterone suppression. The
hyperkalemia can appear within a few days after the onset of heparin therapy.
More rarely, the side-effects alopecia andosteoporosis can occur with chronic use.
As with many drugs, overdoses of heparin can be fatal. In September 2006, heparin
received worldwide publicity when three prematurely born infants died after they
were mistakenly given overdoses of heparin at an Indianapolis hospital.[25]

Antidote to heparin overdose

Protamine sulfate (1 mg per 100 units of heparin that had been given over the past
four hours) has been given to counteract the anticoagulant effect of heparin.[26]
History
Heparin is one of the oldest drugs currently in widespread clinical use.[citation
needed]
Its discovery in 1916 predates the establishment of the Food and Drug
Administration of the United States, although it did not enter clinical trials until
1935.[27] It was originally isolated from canine liver cells, hence its name (hepar or
"ήπαρ" is Greek for "liver"). Heparin's discovery can be attributed to the research
activities of Jay McLean and William Henry Howell.
In 1916, McLean, a second-year medical student at Johns Hopkins University, was
working under the guidance of Howell investigating procoagulant preparations,
when he isolated a fat-soluble phosphatide anticoagulant in canine liver
tissue.[28] In 1918, Howell coined the term 'heparin' for this type of fat-soluble
anticoagulant. In the early 1920s, Howell isolated a water-
solublepolysaccharide anticoagulant, which was also termed 'heparin', although it
was distinct from the phosphatide preparations previously isolated. McLean's work
as a surgeon probably changed the focus of the Howell group to look for
anticoagulants, which eventually led to the polysaccharide discovery.
In the 1930s, several researchers were investigating heparin. Erik
Jorpes at Karolinska Institutet published his research on the structure of heparin in
1935,[29] which made it possible for the Swedish company Vitrum AB to launch the
first heparin product for intravenous use in 1936. Between 1933 and
1936, Connaught Medical Research Laboratories, then a part of the University of
Toronto, perfected a technique for producing safe, nontoxic heparin that could be
administered to patients, in a saline solution. The first human trials of heparin
began in May 1935, and, by 1937, it was clear that Connaught's heparin was a safe,
easily available, and effective as a blood anticoagulant. Prior to 1933, heparin was
available in small amounts, was extremely expensive and toxic, and, as a
consequence, of no medical value.[30]
 7- Diazepam 2ml

Composition

1 tablet contains 2 mg or 10 mg diazepam.

1 ampoule of 2 ml contains 10 mg diazepam.

therapeutic action

Tranquilizer , muscle relaxant , anticonvulsant and antispasticuterin .

indications

Tension , restlessness and agitation , labilitateemotionala , functional

neurovegetative disorders , insomnia, anxiety neurosis , reactive states ,
psychosomatic disease : behavioral disorders in patients chronically psihopatizati ,
acute alcohol withdrawal syndrome , behavior disorders in epileptic seizures and
status epilepticus severe recurrent seizures ( injectable form ) states of contraction
of striated muscle reflex nature ( local inflammation , trauma ) or cause
neurological premedication in anesthesia and surgery and postoperative calming ,
imminent abortion imminent preterm labor or conducting the hypertonic uterine (
injectable form ) .

Directions

oral

adults , one tablet 2 mg or 10 mg 2-4 times / day (after situation ) .

old : 1 tablet 2 mg 1-2 times / day (in needs can grow with caution ) .

Children ( over 6 months) 1/2-1 each tablet 2 mg 2 times / day ( as needed may
increase to as much caution to 0.30 mg / kg / day) .

Intramuscularly or intravenously ( slowly , with caution )

adults and older children :2 -20 mg once (after situation ) can be repeated if
necessary after 3-4 hours.

babies ( more than 1 month) 1-2 mg ( 0.25 mg / kg ) once , it can be repeated if

necessary up to 2 mg / kg / day.

contraindications

Do not use in case of allergy to diazepam, myasthenia gravis, shock , coma , acute
intoxication with alcohol or other central depressant glaucoma .

Precautions

Administer with caution in elderly debilitated ( low dose ) , renal failure and liver .

Pregnancy

Not be used in pregnancy during the first trimester .

Effects on ability to driving or operating other machinery : Prudence in outpatient

as diazepam diminishes the patient's psychomotor performance .

adverse Reactions

Relatively frequent fatigue , somnolence , dizziness , ataxia , headache, light-

headedness , depression, dysarthria , tremor, visual disturbances , diplopia ,
hypotension , nausea , difficulty in micturition , impaired libido , very rarely
leukopenia , jaundice , occasionally hyperexcitability . In patients with small
epilepticus can cause grand mal seizures or status epilepticus installing a tonic.
Administration in high doses for a long time may develop alcohol - barbiturate
addiction type . Injected intravenously (particularly in the elderly , when overall is
altered or when the associated other central depressants ) can cause apnea and / or
cardiac syncope ( recommended low doses , injecting slowly and cautiously ,
health conditions respiration ) are local possible phenomena of irritation and
thrombosis.

6.T. Enatens 10 mg-1/2p * 2ori day ( Enalapril )

Composition

Each tablet contains 10 mg , and 20 mg enalapril maleate and the excipients :

microcrystalline cellulose , lactose , povidone , corn starch , talc , magnesium
stearate .

8- Ramipril 10mg :-

Ramipril is an angiotensin-converting enzyme (ACE) inhibitor, used to treat high

blood pressure and congestive heart failure. It is marketed asPrilace by Arrow
Pharmaceuticals in Australia, Ramipro by Westfield Pharma in
the Philippines, Tritace by Sanofi-Aventis in Italy and United States
and Altace by King Pharmaceuticals in the United States, Ramitens by
PharmaSwiss, Ampril by Krka in Slovenia, Corpril by Cemelog-BRS in
Hungary, Piramil and Prilinda by Hemofarm in Serbia, by Lek in Poland and by
Novartis and Opsonin Pharma Limited as Ramace in Bangladesh, and
in Canada as Altace (Sonfi) and Ramipril

Medical uses
Indications for its use include:

 Hypertension;
 Congestive heart failure;[1]
 Following heart attack in patients with clinical evidence of heart failure;
 Susceptible patients over 55 years: prevention of heart attack, stroke,
cardiovascular death or need of revascularization procedures.
 Diabetic nephropathy (kidney damage due to diabetes)
with microalbuminuria (protein in the urine); in low doses it is used as a
prophylaxis for developing nephropathy and related secondary cardiovascular
events.
Contraindications
Renovascular disease (impaired blood flow in the kidneys), severe renal
impairment (especially in patients with one kidney or with bilateral renal artery
stenosis), volume-depleted patients, history of angioedema while on an ACE
inhibitor, pregnancy, hypotension.

Adverse effects

 low blood sugar (in patients taking medication for diabetes), causing sweating
or shakiness
 dry cough
 dizziness and light-headedness due to low blood pressure
 tiredness and fatigue, especially in the early stages
 mouth dryness in the early stages
 nausea, vomiting, diarrhea (persistent in rare cases)
 fainting
 change in amount of urine
 signs of infection (e.g., fever, chills, persistent sore throat)
 yellowing of eyes or skin, dark urine
 stomach or abdominal pain
 neutropenia (low white blood cells)
[3]
 impotence (erectile dysfunction)

Serious allergic reactions to this drug are unlikely, but immediate medical attention
must be sought if they occur. Symptoms of a serious allergic reaction include, but
are not limited to a rash or swelling of the face, mouth, tongue, or throat.
In extreme cases, ramipril may lead to potentially fatal liver problems.

Mechanism of action
ACE inhibitors, as the name suggests, inhibit the actions of angiotensin converting
enzyme (ACE), thereby lowering the production of angiotensin II and also
decreasing the breakdown of bradykinin. The decrease in angiotensin II results in
relaxation of arteriole smooth muscle leading to a decrease intotal peripheral
resistance, reducing blood pressure as the blood is pumped through widened
vessels. Its effect on bradykinin is responsible for the dry cough side effect.
Ramipril, a prodrug or precursor drug, is converted to the
active metabolite (metabolic product) ramiprilat
by liver esterase enzymes.[4] Ramiprilat is mostly excreted by the kidneys.
The half-life of ramiprilat is variable (3–16 hours), and is prolonged by heart
and liver failure, as well as kidney failure.

9- MAGNESIUM SULPHATE) 25%-5 ml

Magnesii sulfas
Pharmaceutical form: solution for injection
The description of the preparation: Transparent, colorless liquid.
The composition of the preparation: 1 ml solution for injection contains: active
substance: magnesium sulfate 0.25 mg; auxiliary substances: water for injections.
Pharmacotherapeutic and ATC code: Electrolyte. Osmotic purgative.B05X A05
.
PHARMACOLOGICAL PROPERTIES
Magnesium is the second cation according to potassium in intracellular fluid. It is
essential in the activity of many enzymes and enzymatic systems and plays an
important role in the transmission of the nervous impulse and muscle excitability.
Magnesium in the extracellular fluid insufficiency leads to removal of
acetylcholine, increase excitability and muscle tetany, seizures, tingling,
depressive, ventricular tachycardia, extrasistolie, pectoral angor. Decreases the
frequency of sino-atrial node and in high concentrations (more than 15mEq/l)
causes cardiac arrest in diastole. Excess magnesium causes vasodilation through
direct action on the vascular musculature and indirect blockade of ganglia. The
kidney is excreted by glomerular filtration.Has properties hypotensive effects,
sedatives, anticonvulsants and spasmolytic. The intraduodenală stimulates the
release of colecistochinină and elimination of bile from the gall bladder
(colecistocinetic effect).
Taken internally it acts as osmotic purgative.

THERAPEUTIC INDICATIONS
Puseurile with symptoms of hypertensive cerebral edema; Paintball toxicosis late
pregnancy (preeclampsia and eclampsia); convulsive syndrome. Hipomagnezemia
and magnesium deficiency in cases of undernourishment or unbalanced nutrition,
treatment with contraceptives, diuretics, muscle relaxants, chronic alcoholism,
cardiac arrhythmias, particularly those associated with or supraventricular
antiarrhythmic treatment with corticosteroids or diuretics, cardiac glycosides.
Myocardial infarction. The States need in magnesium is increased (load, stress).
Intoxication with mercury, arsenic, lead-driven.

POSOLOGY AND METHOD OF ADMINISTRATION

5-10 ml i.m. or i.v. slowly. It is possible the rapid inhibition of the respiratory
center. Internal 15-30 g as an osmotic cathartic.

SIDE EFFECTS
Perspiraţie, feeling the heat, hypotension, circulatory collapse, cardiac and
CENTRAL NERVOUS SYSTEM depression. Inhibition of breathing is the most
serious struck.

CONTRAINDICATIONS
Diseases of the myocardium or cardiac blockade, myasthenia, severe bradycardia,
severe renal failure, hypotension, inhibition of respiratory center, hypocalcemia,
caşexia.

OVERDOSE
Symptoms: nausea, vomiting, respiratory inhibition, hypotension, bradycardia,
inhibition of CNS and dilating peripheral blood vessels.
Treatment: chloride or calcium gluconate i.v. (100-200 mg of calcium in 15-20
min.). Control of CNS and cardiovascular system
.
WARNINGS AND SPECIAL PRECAUTIONS FOR USE
Can be used in the treatment of status epilepticus (status epilepticus) as an
adjuvant.In the co-administration with CNS depressants or in renal failure will
adjust the dosage of magnesium sulphate.During childbirth may inhibit uterine
contractility.It is recommended always had the chloride or calcium gluconate as an
antidote.

INTERACTIONS WITH OTHER DRUGS

Increases the effects of general anesthetics, depressants and other inhibante
hipnoticelor of the CNS.Calcium ions necessarily antagonize each other effects of
magnesium ions.