It's comprises of a complete case of cerebrovascular accident (stroke) in SOAP format.

1. CASE PRESENTATION ON
HAMMAD KC
IV TH PHARM . D
CEREBROVASCULAR ACCIDENT
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3. PATIENT DETAILS
 Name : XYZ
 IPID : IPID0062194
 Age/Sex : 76/ Male
 Admission Date : 18.06.19
 Department : Neurology (GW 5th floor)
 Weight : 70 Kg
 Discharge Date : 24.06.19
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4. SUBJECTIVE EVIDENCES
 CHIEF COMPLAINTS ON ADMISSION
 c/o forgetting incidence , left hand weakness , deviation of angle of mouth since 1 day
 c/o slurred speech since 2days
 H/O fall from the bed , Incontinence of urine
 PAST MEDICAL HISTORY
 k/c/o HTN since 20 yrs
 k/c/o CVA × 5 yrs back
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5.  PAST MEDICATION HISTORY
 T.AMLONG 10 mg (amlodipine)
 T.LOSAR 25 mg (Losartan)
 T.DEPLATT 75 mg (clopidogrel)
 ALLERGY
 No allergy known
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6.  SOCIAL HISTORY
 Diet : Mixed
 Sleep : Irregular
 Exercise : nil
 FAMILY HISTORY
 father : k/c/o HTN, DM2, Angina
 Mother : k/c/o HTN , DM 2
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7.  PHYSICAL EXAMINATION
 76 years old male patient was admitted in general ward (5th floor) was semi-conscious and
disoriented to time , place and surrounding.
 SYSTEMIC EXAMINATIONS :
CVS : S1 S2 heard
R S : B/L Air entry (+)
Per Abdomen : Soft
CNS : Disoriented , semiconscious , Drowsy
Local examination: Right UL/LL: 5/5
left UL/LL: 3/5
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8.  VITAL SIGNS
 B.P : 160/100 mmHg
 R.R : 20 cpm
 P.R : 128 bpm
 Temperature : Afebrile
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OBJECTIVE EVIDENCES

9. LABORATORYDATA 9
PARAMETER VALUE NORMAL VALUE
Hb (g/dL) 13.2 13 – 18 g/dl
pH 7.38 7.35 - 7.45
TLC 8500 4000 – 10000 cells/cu.mm
Platelet 3.6 1.5 – 4.5 lakhs/cu.mm
Total Cholesterol 225 Less than 200 mg/dl
LDL 147 Less than 100 mg/dl
PT 10.5 11 - 15.8 sec
INR 0.6 0.8 – 1.2
GRBS 145 79 – 160 mg/dl

10.  RADIOGRAPHIC DATA
 X-RAY : lung field are clear , cardiac size is normal , osteoporosis seen in chest
bone
 MRI SCAN : Mild to moderate acute infract in right superior cerebral peduncle ,
infract in bilateral middle and inferior cerebral peduncle.
 ANGIOGRAM : bilateral internal carotid artery show intimal thickening.
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11. PATIENT ASSESMENT
SUBJECTIVE EVIDENCE
 C/O forgetting incidence ,Deviation of angle of
mouth, H/O fall from bed , H/O left hand
weakness , H/O incontinent of urine , c/o
slurred speech.
 Past medical and medication history evidences
 Systemic examination evidences like CNS
 Local examination of arms
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OBJECTIVE EVIDENCE
 LAB investigation like BP, PR, Total cholesterol ,
PT, INR, LDL
 MRI SCAN : mild to moderate acute infract in
cerebral peduncle
 ANGIOGRAM ; Bilateral internal carotid artery
internal thickening

12. PATIENT ASSESMENT
Based on the subjective and objective evidence the patient was diagnosed with
CEREBROVASCULAR ACCIDENT (CVA)
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13.  GOALS OF TREATMENT
 To minimize the signs and symptoms of stroke
 reduce ongoing neurologic injury and decrease mortality and long-term disability,
 prevent complications secondary to immobility and neurologic dysfunction
 prevent stroke recurrence.
 To maintain normal vitals
 To improve quality of life & avoid fresh complaints.
 To provide non-expensive & effective treatment.
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14. PLANNING
 DRUG CHART
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BRAND NAME GENERIC NAME DOSE FREQUENCY
INJ.HEPARIN Heparin 5000U 1-1-1
Inj.STROCIT Citicoline 250mg/ml 1-0-1
T.COLIHENZ Citicoline 500mg 1-0-1
INJ.LEVIPIL levetiracetam 500mg 1-0-1
T.ATORVA Atorvastatin 20mg 0-0-1
T.BETALOC Metoprolol 25mg 1/2-0-1/2
T.PAN Pantoprazole 40mg IV 1-0-1
T.ECOSPRIN Aspirin 150mg 0-1-0
DAY
Day 1 – 3
Day 1 – 3
Day 4 – 5
Day 1 - 4
Day 1 - 5
Day 1 - 3
Day 3 - 5
Day 3 - 4

15.  DRUG CHART
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BRAND NAME GENERIC NAME DOSE FREQUENCY
Syp.POTKLOR Potassium chloride 15ml 1-1-1
Syp.CREMAFIN Mg(OH)² , Liquid paraffin 30ml 1-0-1
DAY
Day 2 - 5
Day 3 - 5

16.  PROGRESS CHART
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DAY 1 Pt. was admitted with given complaints and kept under observation in ICU
for 48 hrs and patient have c/o hematuria
DAY 2 All vitals checked and reported.
No fresh complaints.
DAY 3 Patient became completely conscious, vitals checked and reported
Complaints of constipation
DAY 4 Comprehension of speech
Mild dysarthria
No c/o blood in urine , headache , vomiting
Requested for discharge

17.  GOALS ACHIEVED
 Disease progression is stopped and symptoms are improved
 All vitals came to normal
 Quality of life improved.
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18. PLANNING
 SUGGESTION TO PHYSICIAN
 Drug interactions
1. Heparin + Aspirin : result in potentiated risk of bleeding complication
close monitoring with dose adjustment according to the INR reading.
 Relevant investigation like ECG and CT scan reports are not included.
 Frequency of the past medications is not provided.
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19.  PATIENT COUNSELLING
 Disease related : Cerebrovascular accident also called stroke which is a
condition in which the damage to the brain from interruption of the blood
supply.
 Pharmacotherapy related :
 Citicoline is used for stroke , it’s a nerve protecting medicine , nourish and protect
nerve cell
 Heparin and aspirin is used to prevent blood clots
 Atorvastatin is used to control the blood cholesterol (HMG CoA reductase
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20.  Life style and diet modifications :
 advised to take low fat , slow salted food
 Avoid whole milk , try skim or non fat
 Reduce fatty meat , egg yolk , liver
 Increase intake of nuts , seeds , dry beans
 Increase and promote intake of vegetables and fruits like banana , carrot ,
beetroot, apple etc…
 Learn new ways of cooking like baking or broiling instead of frying
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21.  SUMMERY
Pt. got admitted on emergency basis with chief complaints relevant investigation is done like chest X Ray ,
ECG , MRI scan , MRI Angiogram to confirm stroke.
Hence treatment is started on basis of subjective and objective evidence with drugs like inj.LEVIPIL ,
INJ.STROCIT , T.ATORVA , T.DEPLATT etc..
Later patient improved symptomatically and discharged on following advise
T.DEPLATT 75mg 0-0-1 3 days
T.ATORVA 20mg 0-0-1 6 days
T.PAN 40mg 1-0-1 6 days
Review the doctor after 1 week in OPD
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