CASE PRESENTATION ON HYPERTENSION, TYPE 2 DIABETES MELLITUS,CEREBRO VASCULAR ACCIDENT PATIENT DEMOGRAPHIC DETAILS:- NAME:-AXAB AGE:60yrs GENDER:- Male IP NO.:-18110362 DOA:-25-11-18 DOC:-30-11-2018 BMI:-25.2kg/m² CHIEF COMPLAINTS:- C/o Hiccups from 5 days with sensation of both UL and LL since 3 days , Chest discomfort, Left side weakness PATIENT HISTORY:- PAST MEDICAL HISTORY:-k/c/o Type 2 diabetes mellitus PAST MEDICATION HISTORY:-on prescription since 10 yrs. SOCIAL HISTORY:-Alcoholic FAMILY HISTORY:-NS ALLERGIES:-NKA DIET:-Veg PROVISIONAL DIAGNOSIS:- TYPE 2 DIABETES MELLITUS AND HYPERTENSION PHARMACEUTICAL CARE PLAN:- SOAP ANALYSIS:- TREATMENT GOAL:- 1.Reduce chief complaints 2.Reduce morbidity and mortality 3. Reduce weight 4. reduce infarct size TREATMENT OPTIONS:- 1.ORAL HYPOGLYCEMIC AGENT:- Metformin , glimepiride, tenegliptin 2.ANTIHYPERTENSIVE AGENTS:-ACE inhibitors, ARB s 3. ANTINEUROPATHI AGENTS:-diazepam 4. NSAID s 5.ANTIPLATELET DRUGS PROBLEMS IDENTIFIED:- There is no laboratory data for chest discomfort There is proper long term discharge medication for hypertension There is so many drugs for diabetes it may leads to polypharmacy PHARMACIST INTERVENSION:- 1.Suggest to conduct lab test for chest discomfort 2. Suggest to prescribe long term medication for hypertension 3.Suggest to reduce drugs for diabetes mellitus PATIENT COUNSELLING:- 1.Reduce weight 2.Avoid fatty food and alcohol 3.Intake more fiber rich food like berries, cereals… 4.Be physically active 5.Do physical exercise and walking 6.Reduce stress 7.Take medication properly 8.Regular check-ups THANK YOU Abbreviations:- LL: Lower Limb UL: Upper Limb MRI: Magnetic Resonance Imaging GRBS: Generalized Random Blood Sugar PBS: Post Prandial Blood Sugar NS: Nothing Significant NKA: Nil Known Allergies yrs: Years veg: Vegetarian ACE: Angiotensin Converting Enzyme ARB: Angiotensin Receptor Blocker NSAID: Non Steroidal Anti Inflammatory Drugs These slides provides you information about the case presentation at the basic level of SOAP analysis. This is the live patient's case and we holds confidentiality about the patient's demographic details. This provides an exercising case analysis for the beginners.

1. CASE PRESENTATION ON
HYPERTENSION, TYPE 2
DIABETES
MELLITUS,CEREBRO
VASCULAR ACCIDENT
PRESENTED BY:-
CHANDANA C
2ND PHARM D
Chandana C, Sree Siddaganga College of Pharmacy, Tumkur

2. PATIENT DEMOGRAPHIC
DETAILS:-
NAME:-AXAB
AGE:60YRS
GENDER:- MALE
IP NO.:-18110362
DOA:-25-11-18
DOC:-30-11-2018
BMI:-25.2KG/M2
Chandana C, Sree Siddaganga College of Pharmacy,
Tumkur

3. CHIEF COMPLAINTS:-
C/O HICCUPS FROM 5 DAYS WITH SENSATION OF BOTH UL
AND LL SINCE 3 DAYS , CHEST DISCOMFORT, LEFT SIDE
WEAKNESS
Chandana C, Sree Siddaganga College of Pharmacy,
Tumkur

4. PATIENT HISTORY:-
PAST MEDICAL HISTORY:-K/C/O TYPE 2 DIABETES MELLITUS
PAST MEDICATION HISTORY:-ON PRESCRIPTION SINCE 10 YRS.
SOCIAL HISTORY:-ALCOHOLIC
FAMILY HISTORY:-NS
ALLERGIES:-NKA
DIET:-VEG
Chandana C, Sree Siddaganga College of Pharmacy, Tumkur

5. PROVISIONAL
DIAGNOSIS:-
TYPE 2 DIABETES MELLITUS AND HYPERTENSION
Chandana C, Sree Siddaganga College of Pharmacy,
Tumkur

6. PHARMACEUTICAL CARE PLAN:-
Chandana C, Sree Siddaganga College of Pharmacy, Tumkur

7. SOAP ANALYSIS:-
SUBJECTIVE EVIDENCE OBJECTIVE EVIDENCE
Since 3 days Chest discomfort Abnormal MRI Of brain
Left sided weakness GRBS:-171mg/dl
Sensation of both UL and LL PBS:-200mg/dl
RBS:-176mg/dl
Chandana C, Sree Siddaganga College of Pharmacy, Tumkur

8. FINAL
DIAGNOSIS:-
TYPE 2 DIABETES MELLITUS,
HYPERTENSION
CVA- LATERAL MEDULLARY INFARCT
Chandana C, Sree Siddaganga College of Pharmacy,
Tumkur

9. TREATMENT GOAL:-
1.REDUCE CHIEF COMPLAINTS
2.REDUCE MORBIDITY AND MORTALITY
3. REDUCE WEIGHT
4. REDUCE INFARCT SIZE
Chandana C, Sree Siddaganga College of Pharmacy,
Tumkur

10. TREATMENT OPTIONS:-
1.ORAL HYPOGLYCEMIC AGENT:-
METFORMIN , GLIMEPIRIDE, TENEGLIPTIN
2.ANTIHYPERTENSIVE AGENTS:-ACE INHIBITORS, ARB S
3. ANTINEUROPATHI AGENTS:-DIAZEPAM
4. NSAID S
5.ANTIPLATELET DRUGS
Chandana C, Sree Siddaganga College of Pharmacy,
Tumkur

11. PROBLEMS IDENTIFIED:-
 THERE IS NO LABORATORY DATA FOR CHEST DISCOMFORT
 THERE IS PROPER LONG TERM DISCHARGE MEDICATION FOR
HYPERTENSION
 THERE IS SO MANY DRUGS FOR DIABETES IT MAY LEADS TO
POLYPHARMACY
Chandana C, Sree Siddaganga College of Pharmacy, Tumkur

12. PHARMACIST
INTERVENSION:-
 1.SUGGEST TO CONDUCT LAB TEST FOR CHEST DISCOMFORT
 2. SUGGEST TO PRESCRIBE LONG TERM MEDICATION FOR
HYPERTENSION
 3.SUGGEST TO REDUCE DRUGS FOR DIABETES MELLITUS
Chandana C, Sree Siddaganga College of Pharmacy, Tumkur

13. PATIENT COUNSELLING:-
 1.REDUCE WEIGHT
 2.AVOID FATTY FOOD AND ALCOHOL
 3.INTAKE MORE FIBRE RICH FOOD LIKE BERRIES, CEREALS…
 4.BE PHYSICALLY ACTIVE
 5.DO PHYSICAL EXERCISE AND WALKING
 6.REDUCE STRESS
 7.TAKE MEDICATION PROPERLY
 8.REGULAR CHECK-UPS
Chandana C, Sree Siddaganga College of Pharmacy,
Tumkur

14. THANK YOU
Chandana C, Sree Siddaganga College of Pharmacy, Tumkur