Case presentation on hemiplegia

THIS IS A CASE ON HEMIPLEGIA EVALUATED IN SOAP FORMAT

1. CASE ON HEMIPLEGIA PRESENTED BY: M.SAI SRUTHI II/VI PHARM-D Y17PHD0819 DEPARTMENT OF PARMACY PRACTICE NIRMALA COLLEGE OF PHARMACY

2. CASE SUMMARY A 45 years old female patient is admitted in the hospital on 31/10/18 with the chief complaints of right sided generalized weakness since one month , with vomitings of 10 episodes and left side deviation of mouth. the patient had a past history of rheumatic heart disease. The above case was presented in the format of SOAP ANALYSIS.

3. SOAP ANALYSIS SUBJECTIVE : A 45 years old female patient is admitted in the hospital with chief complaints of right sided generalised weakness since one month,vomitings of 10 episodes and left sided deviation of mouth. PAST HISTORY: k/c/o RHD-MVR with AF(2008) cardio embolic stroke(R.hemiparesis-2014)

4. PERSONAL HISTORY: The patient is taking veg diet. The bowel and bladder movement is normal. Sleep and appetite is low. VITALS: Pulse:92beats/minute Bp:120/90mm of Hg spO2:98 % Temperature : normal Pallor : present

5. OBJECTIVE: BIOCHEMICAL LAB TESTS: SNO PARAMETERS OBSERVED VALUES NORMAL VALUES 1. Bilirubin total 2.42mg/dl 0.1 to 1.2mg/dl 2. Bilirubin direct 0.87mg/dl 0.0 to 0.4mg/dl 3. Bilirubin indirect 1.55mg/dl 0.2 to 1.0mg/dl 4. ALP 134IU/L 37 to 98IU/L 5. Plasma glucose 151mg/dl 70 to 140mg/dl

6. COMPLETE BLOOD COUNT: SNO PARAMETERS OBSERVED VALUES NORMAL VALUES 1. Haemoglobin 10.3g/dl 11 to16g/dl 2. MCH 25.6pg 27 to 35pg 3. Neutrophils 88 % 50 to 81 % 4. Lymphocytes 10 % 14 to 44 % 5. Monocytes 1 % 2 to 6 % 6. Prothrombin time 31.4sec 9.5 to 14.0sec

7. OTHER TESTS: CVS : mitral click+ 2D Echo/ colour / doppler report: RV: Mildly dilated. LA,RA: dilated. Severe TR/mild PAH. Endoscopy report: Erosive gastritis.

8. ASSESSMENT: Based on the sujective and objective evidence the diagnosis is that the patient is suffering from CEREBROVASCULAR ACCIDENT with HEMIPLEGIA. DEFINITION: Complete paralysis of one half of the body including one arm and leg. ETIOLOGY: NON CVA: Neoplasm Infections tauma Demyelination CVA: Thrombus Embolus Hemmorhage

9. RISK FACTORS: NON MODIFIABLE MODIFIABLE Age > 65 HTN Sex: M>F Cigarette smoking. Race : black>white> asian High cholesterole . Family history of stroke. DM Obesity.

10. PATHOPHYSIOLOGY:

11. SYMPTOMS: Difficulty in swallowing. Trouble in vision. Speech becomes difficult. Numbness , tingling. Loss of control over bladder and bowel movement. Feeling depressed. Memory poor.

12. STANDARD TREATMENT: Blood thinners to reduce CV blockages and decrease the chances of future stroke. Antibiotics for brain infection. Muscle relaxants. Surgery to remove swelling of brain. Surgery for muscle contractions,spinal damage,damage to ligaments or tendons on the unaffected area of the body. Exercise therapy to help you remain healthy inspite of your disability. Psycotherapy to deal with psycological effects of the disease.

13. PLAN: MEDICAL: Anticoagulant medication-warfarin. Antiplatelet medication-aspirin. Statins-atorvastatin. Blood pressure medication. Medicines used to treat depression. SURGICAL: Hemorrhagic-aneurysm clipping. Coil embolization. Arteriovenous malfunction repair. GOALS :

14. DRUG CHART: S no Drug name Dose ROA Freq Duration Indication Category MOA Side effects Monitoring parameters 1. T.Lesuride [ levosulpiride ] 25 mg oral OD D2 D3 To relieve GI complication Substituted benzamide selective antagonist of dopamine D 2  receptor activity on both central and peripheral levels. Fever , excessive sweating,gynacomastia . Monitoring dehydration. 2. Inj.Zofer [ondansetron] 1 amp Iv 12 th hr D2 Antiemetic Serotonin 5-HT3 receptor antagonist blocks serotonin. Headache,fatigue,constipation,painful urination. ECG ; K , Mg, serotonin syndrome; decreased bowel activity. 3. Inj.pantocid (pantoprazole) 40mg Iv OD D2 To relieve GI complication PPI suppresses gastric acid secretion by inhibiting the parietal cell H + /K +  ATP pump Headache,skin rash,nausea,vomiting,runny nose ,cough. Bone loss and fractures, CDAD, Mg,serum gastrin levels 4. T.Torvas [atorvastatin] 10mg oral OD D1 D2 Decrease bad cholesterol and TG in blood HMG CO A reductase inhibitor HMG-CoA Reductase Inhibitor Diarrhea , cough,runny nose muscle pain,joint pain. Lipid profile,hepatic,transaminase,CPK

15. S no Drug name Dose ROA Freq Duration Indication Category MOA Side effects Monitoring parameters 5. Cap.becelac forte [ vit supplement] 1cap oral BD D1 D2 Gastrointestinal disorders,decrease cholesterol Vit supplement - Confusion,nausea,allergic reactions. Skin reactions 6. T.Fruselac [spironolactone(50mg), Furosemide(20mg)] ½ tab oral OD D2 D3 Chronic cardiac failure. Antihypertensive Diuretic( Loop) Competes with aldosterone for receptor sites Inhibits Na and Cl Irregular heart beat, headache,weakness,skin rash.  serum electrolytes , Bp Monitor I & O , serum electrolytes, renal function 7. T.digoxin .(digoxin) 0.25mg oral OD D2 Congestive heart failure,AF  Antiarrhythmic Agent Inhibition of the sodium/potassium ATPase pump in myocardial cells Dizziness, rash,nausea,vomoting . Heart rate and rhythm

16. S no Drug name Dose ROA Freq Duration Indication Category MOA Side effects Monitoring parameters 8. Tab.rudimin 1tab oral OD D2 Multivitamin, mulitmineral Vit supplement - Depression,nausea,flatulence,allergic reactions. - 9. T.Calaptin (verapamil) 120mg oral OD D2 D3 Arrhythmia,angina .   Calcium Channel Blocker  Inhibits calcium ion from entering the “slow channels” Headache , constipation , dizziness, nausea,muscle or joint pain. Bp,heart rate 10. T.Acitrom ( acenocoumarol ) 1mg oral OD D1 D2 Anticoagulant  Vitamin K Antagonist Hepatic synthesis of coagulation factors II, VII, IX, and X, proteins C and S Dizziness, head ache, bleeding, hepatotoxicity . CBC 11. T.Zolfresh (zolpidem) 5mg oral OD D3 Hypnotic enhances the activity of the inhibitory neurotransmitter Headache , dizziness,drowsiness . Fall risk ,abuse.

17. DRUG INTERACTION: S no Title Interaction severity Risk rating Patient management 1. Levosulpiride / Loop Diuretics  LD enhance the toxic effect of Levosulpiride . moderate  Avoid combination Do not combine 2.  Verapamil / AtorvaSTATin Increase conc moderate  Consider therapy modification monitor HMG-CoA reductase inhibitor toxicity 3. Digoxin / AtorvaSTATin AtorvaSTATin may increase the serum concentration of Digoxin. moderate Monitor therapy digoxin toxicity  4.  Digoxin / Spironolactone Increase conc moderate Monitor therapy Monitor signs digoxin toxicity

18. S no Title Interaction severity Risk rating Patient management 5.  Spironolactone / AtorvaSTATin Statin increase toxic effect Moderate Monitor therapy Use with caution. 6. Verapamil/digoxin. Bradycardia-Causing Agents enhance moderate Monitor therapy worsening bradycardia 7.  Cardiac Glycosides / Loop Diuretics Enhance toxic effects moderate Monitor therapy Monitor for increased cardiac glycoside toxicity 8. Cardiac Glycosides / Levosulpiride Levosulpiride enhance moderate Monitor therapy nausea, vomiting

19. PATIENT COUNSELLING ABOUT DISEASE: Plegia - weakness,hemi –one side complete paralysis of one half of the body ,including one arm and leg. It is caused due to stroke,thrombus,embolus,hemorrhage,head injury,infections,migraine syndrome.

20. ABOUT LIFESTYLE : Reduce saturated fat and cholesterol. Stop smoking and drinking alcohol. Maintain healthy weight. Eat food rich in veg and fruits. Get regular exercise. Balance training. Electrical stimulation to strengthen muscle.