Case ISCHEMIC STROKE

CASE PRESENTATION ON
ISCHEMIC STROKE
BY, UNDER THE GUIDANCE OF,

NAILA MOHIUDDIN, MOHAMMED FAREEDULLAH,
170715882004 ASSOCIATE. PROFESSOR,
Dept. of Pharmacy Practice.
WHO DEFINATION OF STROKE:
• “Rapidly developing clinical signs of focal (or global) disturbance of cerebral function,
with symptoms lasting 24 hours or longer or leading to death, with no apparent cause
other than of vascular origin.”
CLASSIFICATION OF ISCHEMIC STROKE:
Ischemic Stroke — three subtypes (causes):

• Thrombosis: In situ obstruction of an artery.
• Embolism: Particles of debris originating elsewhere that block arterial access to a
particular brain region.
• Systemic hypo-perfusion: More general circulatory problem, manifesting itself in the
brain and perhaps other organs.
₪SOAP NOTES ₪
SUBJECTIVE DATA:
• An 85yrs. old male patient was admitted in cardiology department with the chief
complaints of weakness of left upper limb and lower limb which was acute in onset.
Fever and chills since 2 days.
• The patient is non alcoholic and a non smoker.
• Patient had a previous history of Hypertension (since 10 years), Diabetes Mellitus type
2(since 3 years) and is thus on medications
– Betaloc (Metoprolol Tartrate – 25 mg/BD) and
– Glycomet (Metformin – 500 mg/BD) respectively.
OBJECTIVE DATA:
• RFT, Sr. Electrolytes, LFT were normal.

BLOOD SUGARS FINDINGS UNIT NORMAL RANGE
RBS 183 Mg/dl 150-200
FBS 115 Mg/dl 70-110
PPBS 100 Mg/dl 110-170
HAEMOTOLOGIC REPORT FINDINGS UNIT NORMAL RANGE
HEAMOGLOBIN 12.5 g/dl 14-18 male

12-16 female
PCV 37 % 41-49
WBC 10,100 cells/cumm 4000-11000
• CAROTID DOPPLER:
Conclusion: mild intima media thickness seen oh both sides (1.3 mm) ;small hyper-cholic
plaque with calcification measuring 9x2mm in right carotid bulb.
• CT SCAN:
Conclusion: infarct with loss of grey white differentiation. A clot in left middle cerebral
artery
FOR
M.
Br. NAME GENERIC NAME
TREATMENT
DOSE
CHART:
ROUTE FREQ. DAY 1 DAY 2 DAY 3 DAY 4 DAY 5
Inj. CLEXANE ENOXAPARIN 20mg IV BD     

Inj. PCM PARACETAMOL 1g IV EVERY 6     
HOURS
Inj HAI HUMAN ACRAPID Acc to SC BD     
INSULIN scale
Tab ECOSRIN ASPIRIN 75mg PO OD     
Tab STORVAS ATORVASTATIN 40mg PO H/S     
Tab OLKEM OLMESARTAN 40mg PO BD     
Tab STAMLO AMLODIPINE 5mg PO BD     
Tab EMBETA-XR METOPROLOL 50mg PO BD     
Inj. STROCIT CITICOLINE 500mg IV BD X    
Inj. MONOCEF CEFTRIAXONE 500mg IV BD X X   

DAY NOTES
DAY 1: DAY 3:
Vitals: – Patient conscious
– Temperature: 102 – Afebrile
– BP:170/60 – Vitals improved
Condition of the patient: – No additional complaints
– Fever with chills CST
– Weakness and pain in upper and lower
limbs DAY 4:
DAY 2,3: – Patient feeling better
– Temperature:101, 99.6 – No fresh complaints
– BP:170/70, 150/70 Patient can be discharged
CST: Add (+) Inj. STROCIT, 500mg, IV,BD- Day 2
+ Inj. MONOCEF, I gm, IV, BD – Day 3
ASSESSMENT:
• Problem 1: Stroke
• Problem 2: Fever
• Problem 3: Hypertension
• Problem 4: Diabetes Mellitus
• Problem 5: Anaemia
PLAN:
• PROBLEM 1: STROKE • PROBLEM 3:HYPERTENSION:

Medication given: Medication given:
– Inj. CLEXANE 20mg BD( ENOXAPARIN) – Tab EMBETA X-R 50mg oral OD (METOPROLOL)
– Tab ECOSPRIN 75mg OD (ASPIRIN) – Tab OLKEM 40mg oral OD (OLMESARTAN)
– Inj STOCIT 500mg BD (CITICOLINE)
– Tab STORVAS 400MG H/S (ATORVASTATIN) • PROBLEM 4: DIABETES MELLITUS:
Medication given:
• PROBLEM 2:FEVER – Inj INSUMAN 10 U BD (HUMAN SOLUBLE INSULIN)
Medication given:
-- Inj PCM 1000mg/iv every 6 hours (PARACETAMOL) • PROBLEM 5: ANAEMIA
– No Treatment Given
DISCHARGE MEDICATIONS:
PHARMACIST INTERVENTION:
• The guidelines for stroke treatment recommend an intravenous time plasminogen

activator (tPa) within 3-4 ½ hrs of onset as it reduces disability. (here the exact time
of onset is unfortunately unknown)
• Atorvastatin is contraindicated in pts. above 75 yrs. of age as it may cause muscle

degeneration and fatigue. Moderate intensity statins like Simvastatin, pravastatin
can be preferred.
• No treatment was given for anemia. Ferrous sulphate, 600 mg/day can be added to
the prescription.
PATIENT COUNSELLING:
• In patients with stroke, once they become clinically stable, the focus of their care shifts
towards rehabilitation.
• Rehabilitation programs are usually facilitated by a team that may include a physician,
physiotherapist, nurse, occupational therapist, speech and language therapist,
psychologist and recreational therapists. Along with family of patient, to provide speedy
adjustments to achieve the primary goal of preventing stroke related complications,
minimizing impairment and functional abilities that promote independence in patient’s
daily living.
• Current evidence indicates that the most significant recovery achievements will occur
within 12 weeks following a stroke.
₪Case reports ₪
Case report 1
• A 20 year old man with no past medical history presented to a primary stroke center with
sudden left sided weakness and imbalance followed by decreased level of consciousness. Head
CT showed no hemorrhage, no acute ischemic changes, and a hyper-dense basilar artery. CT
angiography showed a mid-basilar occlusion.
– He received Alteplase intravenous tPA and was transferred to a comprehensive stroke
center where angiography confirmed mid-basilar occlusion. He underwent mechanical
thrombectomy with recanalization of the basilar artery. His neurological exam improved
and he was discharged to home after 2 days. At his 3 month follow up, he was back to
normal and returned to college
Case report 2
• A 62 year old woman with a history of hypertension and hyperlipidemia presented to a primary stroke center
with sudden onset of weakness of the right side. On examination, she had a global aphasia, left gaze preference,
right homonymous hemianopia (field cut), right facial droop, dysarthria, and right hemiplegia. Head CT showed
only equivocal hypo density in the left middle cerebral artery territory. CT angiography showed a left middle
cerebral artery occlusion.
– She was given Alteplase intravenous tPA at 2 hours from symptom onset and transferred to a
comprehensive stroke center, where digital subtraction angiography confirmed left middle cerebral artery
occlusion. She underwent mechanical thrombectomy with recanalization of the MCA. The next day, she had
only a very mild expressive aphasia and right facial droop. Three months later she had no neurological
deficits (yay).
DISCUSSION
• The above two case reports clearly indicate the beneficiary role of administering Alteplase as
soon as the diagnosis of Ischemic Stroke is made. Recovery is hugely dependent on the factor
of time. In stroke cases, time is brain, brain is time.
• Surgical interventions is also a feasible option. But, here since the patient was geriatric and
had diabetes; surgery were ruled out.
• People have to be made vigilant in regards to identifying the signs and symptoms of stroke and
taking immediate action once it is spotted. Aspirin shouldn’t be taken immediately if stroke is
suspected unlike Heart attack symptoms as, the bleeding may worsen if it’s a hemorrhagic
stroke.
Thankyou!
nailamohiuddin905@gmail.com

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CASE PRESENTATION ON

BY, UNDER THE GUIDANCE OF,

Ischemic Stroke — three subtypes (causes):

• The patient is non alcoholic and a non smoker.

• RFT, Sr. Electrolytes, LFT were normal.

RBS 183 Mg/dl 150-200

FBS 115 Mg/dl 70-110

PPBS 100 Mg/dl 110-170

HAEMOTOLOGIC REPORT FINDINGS UNIT NORMAL RANGE

HEAMOGLOBIN 12.5 g/dl 14-18 male

Inj. CLEXANE ENOXAPARIN 20mg IV BD     

Inj. STROCIT CITICOLINE 500mg IV BD X    

Inj. MONOCEF CEFTRIAXONE 500mg IV BD X X   

• PROBLEM 1: STROKE • PROBLEM 3:HYPERTENSION:

• The guidelines for stroke treatment recommend an intravenous time plasminogen

• Atorvastatin is contraindicated in pts. above 75 yrs. of age as it may cause muscle

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