3. SUBJECTIVE
• Chief complaints: Perioral numbness,paresthesias both hands
since 1day.Vertigo,ataxia since 6am on 29/1/18
• Present illness history: Patient was apparently
assymptomatic1day back then he developed perioral
numbness,parasthesias both hands.H/O vertigo and ataxia
since 6am on 29/1/18
• Past medical history:k/c/o Hypertension, DM II,Diabetic
Neuropathy
• Medication Reconciliation:
T.LOSAR 50mg PO OD -Hypertension
T.GALVUSMET 50/500mg PO BD -DM II
T.GABAPIN 100mg PO TID -DM Neuropathy
8. MRI-
On examination - left pronator drift
On evaluation - MRI brain revealed acute infarct in right
thalamus
9. DRUG CHART
DRUG GENERIC DOSE ROUTE FREQ. CATEGORY INDICATION
IV.Normal
saline
0.9% NaCl 50ml/hr IV STAT Electrolyte Fluid management
Inj.PAN Pantopraz
ole
40mg IV STAT PPI Ulcer prophylaxis
T.ECOSPRI
N
Aspirin 325mg PO OD Anti platelet Stroke
Inj.Clexan
e
Enoxapari
um
40mg S/C BD LMWH DVT prophylaxis
Inj.NOOTR
OPIL
Piracetam 3gm IV Q6H Neuroprotective Stroke
Cap.CoQ Coenzyme
Q10
300mg PO TID Neuroprotective Stroke
10. DRUG GENERIC DOSE ROA FREQ. CATEGORY INDICATION
T.ATOCOR Atorvastatin 40mg PO HS Statin Stroke
T.GALVUSMET Vildagliptin+
Metformin
50/500mg PO BD Antidiabetic DM
T.GABAPIN Gabapentin 100mg PO TID Anticonvulsant Diabetic
Neuropathy
T.LOSAR Losartan 50mg PO OD Anti
hypertensive
Hypertension
11. PHARMACEUTICAL CARE PLAN
SUBJECTIVE
Perioral numbness
Parasthesias both hands
Vertigo and Ataxia
NIHSS - 3
MRS -1
OBJECTIVE
MRI
On examination-
Left pronator drift
On evaluation-
MRI revealed acute infarct in
right thalamus
12. FINAL DIAGNOSIS
• Acute ischaemic stroke secondary to right thalamic infarct
• K/c/o Hypertension,DM II,Diabetic Neuropathy
13. Acute ischaemic stroke
• To re -establish/restore the blood flow
• To reduce the ongoing neurological injury
• To reduce the long term disability
• To reduce any complication(e.g: DVT)
• To prevent recurrance and reocclusion
• To improve quality of life
• To manage BP,Blood sugar and cholesterol levels(Modifiable
RF's)
GOALS OF THE TREATMENT
14. ASSESSMENT
• Based on subjective and objective evidence patient was
diagnosed with Acute ischaemic stroke secondary to right to
thalamic infarct with comorbids Hypertension,DM II,Diabetic
Neuropathy.
• Patient was initiated on
antiplatelets,statins,anticoagulants,supportive&symptomatic
treatment.
• Physiotherapy given.
15. • 0.9%Normal Saline 50ml/hr was given for fluid management.
• T.Aspirin 325mg PO OD was given to reduce the severity of
stroke and to prevent the recurrent strokes.
• Inj.Enoxaparin 40mg S/C BD given to improve decreased
mobility due to stroke and to further prevent deep vein
thrombosis.
• T.Atorvastatin 40mg PO HS was given for secondary prevention
of stroke regardless of baseline cholesterol,as statins reduce the
risk by 30%.
16. • Inj.Piracetam - Cerebroactive Drug 3gm IV 6th hourly given
to improve compromised regional cerebral blood flow.
• Cap.Coenzyme Q10 300mg PO TID was given to protect brain
cell's from oxidative damage of free radicals.
• Patient was a known case of hypertension and DM II.ACE I
or ARB's are preferred antihypertensives in hypertension and
DM II .So patient was on T.Losartan 50mg OD - given to treat
hypertension.
• Patient's with higher intitial Hb1Ac levels may benefit from
initial therapy with 2oral agents or even insulin. So Patient was
on T.Vildagliptin+Metformin 50/500mg PO BD - given to treat
diabetes.
17. • Patient was on T.Gabapentin, an anticonvulsant 100mg PO TID -
given to treat diabetic neuropathy,as it exert a specific analgesic
effect in neuropathic pain
• Inj.Pantoprazlole 40mg IV OD was given for acute stress ulcer
prophylaxis
• Patient symptomatically improved on treatment
• Neurlogically and haemodynamically stable hence discharged.
18. Other medications included in his discharge medication are:
• Insulin therapy should be considered if HbA1c levels is greater than
8-5%-9% even on multiple therapy
• Inj.Lispro insulin 25% + Insulin lispro 75% 25/75 S/C given to
control his blood glucose levels
• T.Alpha-GPC+Piracetam 1tab given as a neuroprotective agent to
improve memory and cognition function
• Cap.Fluoxetine,an SSRI 20mg OD given to prevent depression as
stroke's patients most common psychiatric complication is
depression.
19. PLAN
Recommendations:
• AHA/ASA &JNC7 guidelines recommend an Ace-I and a
diuretic as choice of antihypertensives for preventing recurrent
strokes.
• According to 2018 AHA/ASA Stroke guidelines:
Recent trials of both Pharmacolgical and Nonpharmacolgical
neuroprotective treatment in AIS have been negative.Therefore
Neuroprotective agents may not be required.
20. Monitoring
Disease monitoring:
• BP levels
• Blood sugar levels
• Cholesterol levels
• Neurological status
• Respiratory status
• Oxygen status(Maintain SaO2>94%)
• Careful attention should be given to fluid and electrolyte control
• Look out for infection,haemorrhagic conversion,DVT,aspiration
pneumonia(complications of stroke)
• CBP
22. • Lispro Insulin:Hypoglycemia
• Metformin+Vildagliptin(metabolised in liver):Hepatotoxicity
• Coenzyme 10Q: doses of more than 300mg may affect liver
enzymes
• Fluoxetine:Agitation and dermatological reactions
23. • Drug interactions: Atleast half an hour gap should be
maintained between administaration of these interacting drugs.
• Aspirin+Pantoprazole:Pantoprazole decreases the absorption of
aspirin by increasing the pH.
• Aspirin+Insulin/other diabetic medications:increase the risk of
hypoglycemia.insulin dose adjusment & more frequent
monitoring of blood sugar may be required
24. • Fluoxetine+Aspirin:May increase the risk of bleeding.Monitor
closely
PATIENT COUNSELLING
Disease related(Stroke):
•A stroke occurs when part of the brain loses its blood supply and
stop working
•By making small changes to lifestyle and taking medicines directed
by doctor,risk of stroke can be reduced
25. Drug related/Discharge medication:
• T.ECOSPRIN 150mg 1tab to be taken orally after lunch given
to prevent recurrent strokes
• T.ATOCOR 40mg 1tab to be taken orally after dinner -given to
prevent recurrent strokes
• T.LOSAR 50mg 1tab to be taken orally once daily- given to
control BP levels
• T.PIRANULIN(Alpha GPC+Piracetam) to be taken orally twice
daily - to improve cognitive function&memory
• Cap.CoQ(Coenzyme 10Q) 300mg 1Cap to be taken orally thrice
daily-for neuroprotection
26. • Cap.FLUDAC(Fluoxetine) 20mg 1cap to be taken orally once
daily -for prevention of depression.
• INJ.HUMALOG MIX 25/75 UNITS to be taken as - 25units
subcutaneously before breakfast,15units subcutaneously before
dinner-given to control blood sugar levels.
• T.GALVUSMET 50/500mg 1tab to be taken orally twice daily
before breakfast and before dinner-given to control blood sugar
levels.
• Cap.GABAPIN 200mg 1cap to be taken orally thrice daily-given
to improve neuropathic pain.
27. • INJ.HUMALOG MIX 25/75 UNITS to be taken as - 25units
subcutaneously before breakfast,15units subcutaneously before
dinner-given to control blood sugar levels
• T.GALVUSMET 50/500mg 1tab to be taken orally twice daily
before breakfast and before dinner-given to control blood sugar
levels
• Cap.GABAPIN 200mg 1cap to be taken orally thrice daily-given
to improve neuropathic pain
28. LIFE STYLE MODIFICATIONS
• Manage high BP:Consume a diet rich in fruits,vegetables&low
fat dairy products(DASH diet)
• Dietary Na restriction ideally LT 2g/day
• Maintain normal cholesterol levels:Lower the amount of
cholesterol and saturated fat in your diet.
• Keep diabetes under control:Appropriate self monitoring of blood
glucose(SMBG). Take Diabetic diet:The meal plan should be
moderate in carbohydrate&low in saturated fat.
• Increase physical activity:Engage in regular physical activity
such as brisk walking(atleast 30mins/day)
29. Rehabilitation:
• Stroke rehabilitation can help you regain independence and
improve QOL
• Rehabilitation may take weeks to months and usually requires
a healthcare team approach for success
