Ischemic stroke explained with example of patient by soap note including all drugs , treatment, pharmacological treatment,non pharmacological treatment and councelling advices to the patient. You can gain a huge knowledge on case reviewing in soap note. It includes pharmacological treatment as well as non pharmacological treatment, councelling of patient.

1. CASE STUDY ON ISCHEMIC STROKE

2. SOAP NOTE
Subject

3. • Name:xyz
• Sex:F
• Dept: General medicine.
• ROA:C/O weakness of LT UL&LT LL since yesterday evening
6pm,
C/O slurring of speech since yesterday evening 6pm.
• Past history:H/O weakness of LT UL&LT LL and slurring of
speech.
• Family history: No similar complaints.
• Person history: Patient takes mixed diet,
Bladder & bowel –normal,
Sleep-normal.
• Smoker:Yes.
• Alcoholic: No.

4. OBJECTIVE

5. • G/E : Blood pressure:100/60 mmHg
Pulse rate :64/min
SpO2 : 96% with R.A.
• S/E : CNS-HMF
Pupils-B/L reacting to light
CVS-S1,S2 +

6. ASSESSMENT
ISCHEMIC STROKE

7. • Ischemic stroke:
It occurs when blood supply to brain parts is interrupted or
reduced, preventing brain
tissue from getting oxygen and nutrients.
• Causes:
Common type of stroke happens when a blood clot blocks
the flow of blood and oxygen
to the brain.

8. • Symptoms:
1. Sudden weakness or numbness of face, arm or leg
(Especially in one side of the body).
2. Sudden confusion trouble speaking or understanding
of speech.
3. Sudden trouble seeing in one or both of the eyes.
4. Sudden severe headache with no causes.
5. Sudden trouble making,loss of balance or coordination.

9. • Diagnosis:
CT scan or MRI scan.
• Pathophysiology:
Ischemic stroke is caused by “deficiency of blood&
oxygen to the brain”.

10. PLAN

11. Drug Name Dose Frequency ROA
Inj.Ceftriaxone 1gm BD IV
Inj.Pantop 40mg OD IV
T.Aspirin 150mg OD ORAL
T.Clopidogrel 75mg OD ORAL
T.Atorvastatin 40mg OD ORAL
T.BC/Vit-D3 - OD ORAL
RT feedings 120ml 2hrly ORAL
And PHYSIOTHERAPY

12. • Inj.Ceftriaxone:
To treat the bacterial infections.
Adverse effects:Chest pain, Shortness of breath
Sore throat,black stools.
• Inj.pantop:
To treat Gastro-esophageal reflux&heart burn.
Adverse effects:Blurr vision,dry skin, increases hunger

13. • T.Aspirin:
To relieves the headache.
Adverse effects:Cloeudy urine, abdomen pain.
• T.Clopidogrel:
To prevent the blood clots.
Adverse effects: Headache,nausea,vomitings.

14. • T.Atorvastatin:
To reduce the risk of cerebral
infraction.
Adverse effects: Nose bleeds,sore throat,
diarrhoea.

15. PATIENT COUNCELLING:
• Advice the patient to avoid smoking.
• Advice the patient to do some low intensive exercise.
• Advice the patient to reduce the sugar, salt intake in diet.
• Advice the patient to reduce the cholesterol content in diet.
• Advice the patient to avoid tension and stress.
• Advice the patient to do meditation.

16. THANK YOU