A 42-year old male patient presented with symptoms of right-sided body weakness, slurred speech, and loss of consciousness. He was diagnosed with a hemorrhagic stroke caused by a left capsulaganglionic bleed based on his MRI results. He was treated with medications to control blood pressure and prevent further complications. Through physical therapy and treatment, the patient's symptoms improved and he was discharged upon being able to follow commands and having normal vital signs.

1. CASEPRESENTATIONON STROKE
BY HEMA SREE
PHARM D 4th
year

2. INTRODUCTION
HEMORRHAGIC STROKE : It is rupture of blood
vessels in or on the surface of brain with bleeding
into surrounding tissues
RISK FACTORS :
• Age > 80yrs
• HTN
• Previous history of ischemic stroke
• AVM
• Coaugulopathy
• Aneuyrsm

3. CLASSIFICATION
• 3 types – sub- arachonoid
intra-cerebral
subdural hematoma
SYMPTOMS
 Weakness in one side of body
 Ataxia
 Dysarthria
 Vertigo
 Asphasia
 Syncope
 Facial dropping
 Photophobia
 Pain in eye movement

4. PATHOPYSIOLOGY
Death
Decrease blood flow and platelet aggregation
Clot formation and elevates ICP
Further causes neurotoxicity of blood contents
Causes damage to surrounding tissue causing mechanical stress
Presence of blood or blood clots in brain parenchyma
Blood may enter through rupture of aneurysm

5. DIAGNOSIS
• MRI SCAN
• CT SCAN
• ECG
• CBP
• Carotid doppler
• Coagulation studies

6. TREATMENT
NON- PHARMACOLOGICAL
• Mechanical thromboectomy
• Revascularisation
• Rehabillation
• Surgical intervention to
either clip or abloate
vascular abnormality
• Surgical compression of
heamotoma
PHARMACOLOGICAL
• Anti hypertensives like Ca++
channel blockers, ARB OR
ACE inhibitors
• Hemostatic agents[ eptalog
alfa vii a DOSE- 20 -
80µg/day]
• Mannitol 15-20 % over 1hr

7. PATIENT PROFILE
FORM

8. DEMOGRAPHIC DETIALS
• Name : ABC
• Age : 42yrs
• Gender : Male
• IP No : 461258
• Department:Neuroward
• DOA : 2/ Sept/
2019
• Height : 172cm
• Weight : 90kg
• BMI : 30kg/sqmm

9. CHIEF COMPLAINTS
• c/o right side body weakness
• slurring of speech
• Deviation of mouth
• Loss of consciousness
PRESENT HISTORY
• A 42yr old male patient presented with H/O right
side body weakness, slurring of speech, deviation
of mouth and loss of consciousness for further
management and treatment

10. PAST HISTORY :
• H/O Ischemic stroke
• S/P Thrombocytosis
• C-PAP
• Previously had seizures[5yrs back]
• HTN – Tab. Nicardia 20mg TID

11. PROVISIONAL DIAGNOSIS
• MIGRAINE HEADACHE..?
• SEIZURES..?
• FACIAL PARALYSIS..?
• HEMORRHAGIC STROKE..?

12. DAY TO DAY ASSESMENT
DAY – 1
• c/o slurred speech
• Deviation of mouth
• Not using c-pap since
2days
DAY -2
• Patient conscious,
oriented
• slurred speech +
DAY – 3
• Following commands
• Normal vitals
• Physiotherapy
recommended

13. • DAY – 4
• Patient conscious/
coherent/ following
commands/ afebrile
• Vitals –normal
• Physiotherapy
recommended
DAY – 5
• Following commands
• Physiotherapy
continued

14. Physiotherapy Progress Notes
Day-3 [4/9/19]
• Limb physio done
• Spirometry
DAY -4 [5/9/19]
• AROM[Active Range Of
Motion]
• Spirometry
• Pelvic bridging
• Amputation
DAY-5 [6/9/19]
• AROM
• Co-ordination training
• spirometry

15. ICU COURSE TREATMENT
• Admission date – 2/9/19 Transfer date- 4/9/19
ICU Admission Diagnosis : Stroke – left capsuloganglionic bleed
• A 42 yr old male patient known case of HTN, old CVA [left
hemiporesis] presented with slurred speech, deviation of mouth,
loss of consciousness.
• Patient has history of thrombolysis 2014. Acc to MRI brain pt has
left capsuloganglionic bleed. Pt also has uretheral bleed and
hematuria.
• Inview of OSA and using c-pap pt referred pulmonology. Advised for
continuing BiPAP over night.
• In ICU patient was managed by antiiotics, anti-hypertensive, PPI’S,
nebulisation.
• Now patient is hemodynamically stable and shifted to neuroward

16. PHYSICAL EXAMINATION
VITALS
• TEMP -99degrees celscius
• PR – 9O /min
• BP – 150/100mmhg
CNS – slurred speech
Rt U/L Ataxia +

17. LABORATORY VALUES
PARAMETER RESULT NORMAL VALUE
Heamoglobin 13.8 11-16gm/dl
RBC 4.93 3.80-5.80million/cumm
PCV 40.20 35-50%
Platelet count 2.09 1-4lac/cumm
TLC 6,330 3500-10000/cumm
PTT 1.30 60-90secs
INR 1.03 <1.1
GRBS 144.00 140-200
Sr. sodium 141 135-143mEq/L
Sr.potassium 3.5 3.5-5.5mEq/L
Sr.chloride 104 98-107mEq/L
Sr. creatinine 1.00 0.6-1.1mg/dl

18. PARAMETER RESULT NORMAL VALUE
T.Bilirubin 6.56 0.5-1.1mg/dl
D.Bilirubin 0.00 0-0.35mg/dl
I.Bilirubin 0.40 0-0.65mg/dl
SGOT 26.00 6-38IU/L
ALP 46.00 36-142mmo/l
T.PROTIENS 7.60 6.8-3.3g/dl
A/G RATIO 1.20 Approx 1
Albumin 4.20 3.5-5.0g/dl
Gobulin 3.40 2-3.5g/dl
Blood urea 26 3-8mmol/L
Urea N2 1.81 2.5-7.1 mmol/L

19. Real time ultrasonography
• Urinary bladder is empty with foley bulb insitu
• Impression: no significant abnormality detected
Doppler study of carotid/vertebral
• Impression: no evidence of carotid artery
stenosis
MRI BRAIN
• Impression : STROKE –Left Capsuloganglionic
bleed

20. MEDICATION CHART
BRAND GENERIC DOSE ROA FREQ D-1 D-2 D-3 D-4 D-5 D-6
IVF NS Normal saline 1ooml IV Per hr + + + + + +
INJ.PAN Pantoprazole 4mg IV OD + + + + + +
INJ.ZOFER Ondansetron 40mg IV TID + + + + + +
INJ.OPTINE
URON
Vit B complex 3ml IV OD + + + + + +
INJ
NEOTROPIL
Piracetam 3g/15
ml
IV TID + + + + + +
TAB.ROUVA
S
Rosuvastatin 40mg PO HS + - - - - -
INJ
MAGNEX
FORTE
Cefaperazone
+ Salbactum
1.5g IV BD - - + + + +

21. BRAND GENERIC DOSE ROA FREQ D-1 D-2 D-3 D-4 D-5 D-6
SYP.DUPHLAC lactulose 30ml PO BD - - + + + +
NACL 0.9% Sodium
chloride
P/N TID - - + + + +
T.NICARDIA Nifedipine 20mg PO TID - - + + + +
OTRIVIN
NASAL
DROPS
Xylometazolin
e
TID - - + + + +
T.COLIHENZ Citicholine +
piracetam
800m
g
PO BD + + - - - -

22. SOAP
ANALYSIS

23. SUJECTIVE DATA
• Right side body weakness
• Slurred speech
• Deviation of mouth
• Loss of consciousness
• ataxia

24. OBJECTIVE DATA
• MRI Brain – left capsuloganlionic bleed
• T.BILIRUBIN – 6.56mg/dl[high]
• Blood urea – 26mmol/l[high]
• Urea nitrogen – 1.81mmol/l[low]

25. ASSESSMENT
• Based on subjective and objective data the
patient was diagnosed with STROKE –
CAPSULOGANGLIONIC BLEED

26. PLANNING
GOALS OF TREATMENT
• Reduce the ongoing neurological injury
• Decrease mortality
• Decrease long term disability
• Prevent reoccurrence of stroke
• Prevent further complications secondary to
immbolity and neurological dysfunction

27. TREATMENT OPTIONS
INJ. NOOTROPIL
• MOA – It works by
improving blood flow and
oxygen to the brain
• Uses – cognitive enhancer,
stroke
• Side effects- wt gain,
weakness, stomach pain
• MP- LFT, RR
TAB. ROSUVAS
• MOA- competitive inhibitor
of HMG-COA reductase,
reducing choloesterol
synthesis
• USES- cvs diseases, high
cholesterol levels
• SE – joint pain, indigestion,
loose stools
• MP – Lipid profile ,
creatinine phosphodikinase

28. OTRIVIN NASAL DROPS
• MOA – works by shrinking
blood vessels in nasal
passage
• Uses - obstrutctive sleep
apnea, nasal congestion
• SE – Dry mouth, throat,
burning or stinging
sensation
• MP - BP
TAB. NICARDIA
• MOA –calcium channel
blocks an decreases BP
• USES – HTN
• SE- dizziness, flushing,
cough
• MP – BP, ECG, O2 saturation

29. Tab. COLIHENZ
• MOA- citicoline works by replenishing
necessary chemicals in brain & regulate
process of cognition & play vital role in neural
communication
• USES – Sroke
• SE –SOB, agitation and anxitey
• MP – bp, ECG, LFT

30. PROBLEMS IDENTIFIED
UNTREATED INDICATON
• Blood urea and urea
nitrogen levels are
abnormal but no drug is
given
• Total bilirubin level is also so
high but still it is not treated
UNINDIACTED MEDICATION
• SYP. DUPHLAC is given even
though no complaint of
constipation

31. •NILADR
•NILDrug
INTERACTIONS

32. GOALS ACHIEVED
• Blood pressure was controlled
• Patient gained consciousness
• Patient was oriented and slurred speech
reduced

33. MONITORING PARAMETERS
• Blood pressure
• CBP
• LIPID PROFILE
• Urine analysis
• ECG

34. PATIENT COUNSLLING
ABOUT THE DISEASE
• A stroke is a neurological illness
that occurs when blood flow to
brain is interrupted.
• Discuss stroke risk factors as this is
2nd attack of stroke
• Explained further complications of
stroke like cvs disease, seizures
etc..

35. ABOUT MEDICATIONS
• Do not withdraw suddenly the drugs cognitive
enhancers as the cause withdrawl symptoms
• Follow the medications as per the prescription
• Do not miss the dose
• Do not double the dose
• If any ADR seen report to physician
immediately

36. LIFESTYLE MODIFIACTIONS
• Begin an exercise program
• Limit the alcohol intake
• Avoid smoking
• Know your cholesterol level
• Learn stress management
• Avoid wearing tight dresses

37. DIET
Foods to avoid
• Reduce the amount of salt
• Reduce the amount of fat and choloesterol
• Limit vegetable oils and nut oils
• Limit sweets and processed foods such as chips ,
cookies & BAKED FOODS
• Do not eat trans foods
• Don’t eat any food that has hydrogenated listed
in its ingridients

38. • Foods to be taken
• Eating more fresh
vegetables and fresh fruits
• Eating more lean proteins,
such as fish, poultry
• Using low fat dairy
products
• Olive oil is recommended
• Avacados, flax seed ,
tomato, red wine can be
taken

39. REFRENCES
• DIPIRO Textbook
• WIKIPIDEA
• WWW.DRUGS.COM
• WWW.WEBMD.COM
• WWW.UKHEALTH.COM
• HEALTHLINE.COM

40. THANK YOU