CASE

PRESENTATION
Case presentation
by
BY
P.HEMA
P.HEMA
GUIDED BY

GUIDED
BY
sravan kumar

contents
Patient details
Chief complaints And Past History
Examination And Lab Investigation
Diagnosis
SOAP ANALYSIS
Pharmaceutical issues
Discharge medication
Suggestions and patient education

Patient details
Name:Ramayya
Age :73yrs
Sex
:male
Ward : CCU

CHIEF COMPLANTS
s

Dysphagia
Decreasedfood intake
Fever

PAST
------- HISTOR
HYPER TENSION
[not using medication]

PHYSICAL
EXAMINATIONS
B.P:160/90mmhg
Temperature:100F
Pulse rate:24

DIAGNOSIS

ISCH55AEMIC STROKE
WITH
LEFT HEMIPLEGIA

investigations
Blood group
haemoglobin
Plate let count

normal

result
A+ve
13g/dl

2.4lak/cum

Blood suger

1.5-5
lak/cumm
80-140mg/dl

neutrophills

60-70%

86%

lymphocytes

40-50%

14%

84mg/dl

Total count

10,600

QBC

-ve

----s.Total bilirubin
SGPT
Direct bilirubin
Indirect bilirubin
SGOT
Alkaline phosphate
Serum creatine
Blood urea
Serum sodium
Serum chlorides

LIVER FUNCTION TESTES

0.2-1mg/dl
5-35
0.0-0.2mg/dl
0.2-1mg/dl
8-45
36-141u/l
0.9mg/dl
20-40mg/dl
135155mmols/l
98-109mmols/l

0.7mg/dl
57
0.2mg/dl
0.5 mg/dl
42
82u/l
1.1mg/dl
40/dl
148mmol/l
120mmols/l

URINE ANALYSIS
Albumin : ++
RBCS

:3-4cells

Glucose : nill
Microbes :plenty of pus cells

Color doppler studyof carotids

ICA/CCA RATIO
Systolic-1.19-1.8
Diastolic-1.76-2.4
IMPRESSION :
Iso echonic thrombus in RT.ICA
Monophasic flow in Rt CCA

MRI REPORTS
sssssssssssss
ventricular system &extracerebral
spaces are midely prominent
cerebral atrophy
arteriosclerosis

DRUG

DOSE

FREQUENCY

CATEGORY

enaxoparin

0.4cc

o.d

anticoagulant 8days
s

tab.
pantaprazole

40mg

o.d

Protan pump
inhibitors

8days

Inj.Cef
triaxone

1g

b.d

antibiotic

8days

Tab.
atorvastin

80mg

o.d

Tab.
parecetamol

650mg

sos

Anti pyretic

Syp. gluserol

30ml

t.d

constipation

Inj.piracetam

1amp

tid

Nootropic
agent

1day

Tab.clopidogr
el

75mg

o.d

Anti platelet
agent

8days

Tab.beclofen

5mg

b.d

Anti spastic

3,4 days

stat

Anti emetic

3-8 days

Inj.
metoclopram
ide

DURATIONinj.

8days
3days
3days

DRUG

FREQUENC
E

CATEGORY

DURATION

Inj.
100ml
paracetamol

o.d

antipyretic

On 4 th day

Inj.cetirazine

stat

anti
histamine

On 7th day

T.D

Nootropic
agent

1-8
DAYSSYP.

syp.citocolin 5ml

B.D

Psychostimu 4-8 DAYS

lent

SYP.
cremaffin
plus

HS

laxative

SYP.Pireceta
m

DOSE

1amp
10ML

30ML

4-8 days

Inj
fevastin[par
acetamol]

1amp

stat

Anti pyretic

Acetyl
cystein

3cc

t.d

In
pacetamol
over dose

5day

SURGICAL TREATMENT

Carotid Endarterectomy
Carotid endarterectomy, also called
carotid artery surgery, is a procedure in
which blood vessel blockage (fatty
plaque) is surgically removed from the
carotid arte

Angioplasty/Stents
Doctors sometimes use balloon
angioplasty and implantable steel screens
called stents to treat cardiovascular
disease and help open up the blocked

Ppharmaceuticals issues
Beclofen is contraindicated in
ischaemic stroke
ceftriaxone +warfarin: increase the
effects of warfarin by anticoagulation

PATIENT COUNSILLING

Avoid smoking as smoking damages the smooth lining of

blood vessels and increases the chances of blocked arteries
Eat a diet low in saturated fat, high in protein, high in
fibre with plenty of fruits and vegetables.
Avoid /reduce alcohol intake
Exercise regularly
Follow stress busting techniques to alleviate streSS
Maintain normal hyper tension