1. What additional issues would you like to assess regarding the case?

1. The reasons of not using fibrinolytics as a reperfusion strategy should be

included and evaluated.

2. The exact timing of admission and symptoms onset should be included

for evaluation of proper timing of initiation of relevant medications, esp aspirin, metoprolol, clopidogrel, etc.

3. Renal clearance should be estimated based on SCr (even if BW & Ht are

not available, the CrCl adjusted to BSA 1.73m2 can be estimated to serve as a reference).

4. Latest vaccination status should be included (indicate N/A if not

available).

2. Do you have any additional assessment points regarding the cases

drug therapy? Or alternative views? Please list here.

1. Loop diuretics are generally not quite effective in treating CCB-induced

ankle edema as the condition is not caused by volume overload. (The problem can be effectively relieved by RAS blockade, eg with ACEI/ARB) See UKMi Q&A: How should ankle oedema cause by calcium channel blockers be treated?

2. The preferred LDL target should be 1.8 mmol/L according to ATPIII (2004
update) for very-high risk patient, eg ACS patient with DM.

3. Aspirin 300mg stat po should have been administered initially as a

loading dose.

4. Should metoprolol be withheld when pulse less than or equal 50 bpm? 5. Amlodipine was also withheld upon admission initially but this change
was not stated in Summary of hospital stay.

6. Spironolactone is recommended for AMI patients already taking

therapeutic dose of ACEI, without significant renal dysfunction or hyperkalemia, with DM or heart failure, and with LVEF below or equal to 40%. This pts LVEF is >40% and thus spironolactone is not indicated at this stage yet.

7. Pneumococcal vaccine should also be recommended according to CDC

guideline.

8. The dose-limit for drug-drug interactions between amlodipine and

simvastatin (max 20mg nocte) should be stated for clearer explanation.

9. Insulin infusion is recommended during acute phase of STEMI for

stringent glucose control but was not initiated in this case.

10. In the part of non-compliance, the pt is likely to have compliance

1

problem with aspirin and clopidogrel as well (not just with DM and lipid drugs), especially because these 2 drugs were newly initiated.

11. Since pt is newly started on aspirin and clopidogrel, the side effects
of them should be counseled, eg signs & symptoms of bleeding.

12. The DRP of starting beta-blocker in STEMI pt with signs of CHF

should be regarded as improper drug selection instead of suboptimal/subtherapeutic dose.

3. Please provide any additional suggestions for future improvement of

the students assessment.

1. 2. 3. 4.

Use of more updated guidelines and clinical trials results is preferred. Reference ranges for lab values should be included. State the diagnosis clearly in case notes. Minimize typos, including dates, eg metformin stop date should be 26/6 not 26/9.

5. Minimize grammatical errors for clarity. 6. The table in the top part in page 2 is a bit redundant and similar
information has been repeated in a later part.

7. Duration of MPTA should be included to help readers better assess preadmission pharmacotherapy status.

8. Reference related to the latest FDA update on simvastatin drug

interactions should be included in the reference list.

9. The stop date of a particular medication should not be the discharge

date if that medication still needs to be taken after discharge.