SILLIMAN UNIVERSITY MEDICAL SCHOOL

SUBMITTED TO: DR.

SUBMITTED BY:

REPRESENTATIVE CASE
1) IDENTIFYING DATA:
2) CHIEF COMPLAINT:
3) MEDICAL HISTORY

A)HISTORY OF PRESENT ILLNESS:

B) PAST MEDICAL HISTORY:

C)FAMILY HISTORY:

D)PERSONAL AND SOCIAL HISTORY:

REVIEW OF SYSTEMS PHYSICAL EXAMINATION

General Survey: General Survey:
HEENT: Vital Signs: BP: HR: Weight:
Chest and Lungs: RR: Temp: O2 sat:
Cardiovascular: Skin:
Gastrointestinal: Chest/ Lungs:
Musculoskeletal: Cardiovascular:
Genitourinary: Abdomen:
Peripeheral Vascular: Genitourinary:
CNS: Extremities:
CNS:
PRIMARY WORKING IMPRESSION
DIAGNOSIS RULE IN

III. DIFFERENTIAL DIAGNOSIS

DIAGNOSES RULE IN RULE OUT

1.
2.
3.
4.
5.
6.
7.
8.
9.
IV. RATIONAL LABORATORY & DIAGNOSTIC TESTS
PATIENT NORMAL
LAB. TEST INTERPRETATION/NECESSITY AVAILABILITY COST
RESULTS VALUES
HEMATOLOGY

BLOOD CHEMISTRY
IMAGING STUDIES

PATHOPHYSIOLOGY

FINAL DIAGNOSIS
Based on the history, physical examination, and laboratory results presented, the diagnosis is Pernicious Anemia 2˚ Autoimmune Atrophic
Gastritis
V. THERAPEUTIC MANAGEMENT
LIST OF PROBLEMS THERAPEUTIC OBJECTIVES
1. Hypertension  To control and monitor the BP before undergoing rTPA.
2. Tachycardia  To monitor and prevent further neurologic deficit.
3. Obesity (Class I)  To control the patient’s glucose level.
4. Abnormal Neuroexam  To address the patient’s dyslipidemia.
5. Diminished DTR on R side  To educate the patient of lifestyle changes that will affect the
6. No withdrawal response to pain patient’s future.
7. Flaccid R arm and leg
8. Positive Babinski Sign
9. Global Aphasia
10. Dyslipidemia
11. Pre-Diabetes
12. Smoker
13. Mild AR
14. Occlusion of LMCA and R External Carotid Artery
ADVICE AND INFORMATION NON-PHARMACOLOGIC MANAGEMENT
1. Educate the patient and family about her disease to 1. Admit the patient in the ICU under the resident on duty.
assure compliance. 2. Secure consent to care
2. Advice patient on lifestyle modifications like smoking 3. Monitor V/S q 1h with neuro vital signs for the possibility of
cessation and losing weight to control the patient’s deterioration and possible intubation
hypertension and dyslipidemia. 4. Monitor I and O q shift
3. Educate the patient of possible decompressive 5. NPO initially
craniectomy or thrombectomy, its advantages and 6. Insert NGT, start feeding after 6-8 hrs at 1,800cal in 1,800cc
disadvantages. water in 6 equal feedings at 300cc/feeding
4. Educate the patient on importance of physical therapy to 7. Start IV PNSS 15gtts/min
help the patient regain normal daily activities. 8. Additional Labs:
Glucose monitoring q 6h, maintain at 140-180 mg/dL
9. When stable, start physical therapy/occupational therapy
10. Aspiration precaution/Bedsore Precaution
11. Suction secretions as need
PHARMACOLOGIC MANAGEMENT
DRUG NAME EFFICACY SAFETY SUITABILITY
CA CHANNEL BLOCKER  Short-term treatment of  Contraindications:  Incompatible w/ Na
hypertension Patients w/ advanced bicarbonate 5%,
Nicardipine IV  Nicardipine is a aortic stenosis, unstable furosemide,
dihydropyridine Ca angina, cardiogenic ampicillin/sulbactam,
channel blocker. It shock. acute angina ampicillin, thiopental,
inhibits Ca ion from attack. Use w/in 1 mth of cefepime, micafungin,
entering the slow MI. Lactated Ringer's inj.
channels or select  Caution: Patients w/
voltage-sensitive areas of acute cerebral
vascular smooth muscle infarction or
and myocardium during haemorrhage, CHF,
depolarisation, producing HTN associated w/
a relaxation of coronary phaeochromocytoma,
vascular smooth muscle portal HTN. Hepatic
and coronary and renal impairment.
vasodilatation. It also Pregnancy and
increases myocardial lactation.
oxygen delivery in
patients w/ vasospastic
angina.
 Rapidly and completely
absorbed from the GI
tract. Bioavailability:
Approx 35%. Time to
 peak plasma
concentration:
Immediate-release cap:
30-120 min; sustained-
release cap: 60-240 min.
IV rTPA The National Institute of
Neurological Disorders and Stroke
(NINDS) rtPA Stroke Study
showed a clear benefit for IV rtPA
in selected patients with acute
stroke. The NINDS study used IV
rtPA (0.9 mg/kg to a 90-mg
maximum; 10% as a bolus, then
the remainder over 60 min)
versus placebo in ischemic stroke
within 3 h of onset. One-half of the
patients were treated within 90
min. Symptomatic intracranial
hemorrhage occurred in 6.4% of
patients on rtPA and 0.6% on
placebo. In the rTPA group, there
was a significant 12% absolute
increase in the number of patients
with only minimal disability (32%
on placebo and 44% on rtPA) and
a nonsignificant 4% reduction in
mortality (21% on placebo and
17% on rtPA). Thus, despite an
increased incidence of
symptomatic intracranial
hemorrhage, treatment with IV
rtPA within 3 h of the onset of
ischemic stroke improved clinical
outcome.
CA CHANNEL BLOCKER  primarily for patient’s BP
maintenance
Amlodipine  Amlodipine, a
dihydropyridine Ca-
channel blocker, reduces
peripheral vascular
resistance and BP by
relaxing coronary
vascular smooth muscle
and coronary vasodilation
through inhibition of Ca
ion transmembrane influx
into cardiac and vascular
smooth muscles.
ANTIPLATELET AGENT  Oral form may be for acute
ischemic stroke
Aspirin  Aspirin is a salicylate that
exhibits analgesic, anti-
inflammatory, and
antipyretic activities. It is
a selective and
irreversible inhibitor of
cyclooxygenase-1 (COX-1)
enzyme resulting in direct
inhibition of the
biosynthesis of
prostaglandins and
thromboxanes from
arachidonic acid.
Additionally, it also
inhibits platelet
aggregation.
 Synonym: acetylsalicylic
Contraindication Inidcations:
 Sustained BP >185/110 mmHg  Clinical diagnosis of stroke
 despite treatment  Onset of symptoms to time of
 Bleeding diathesis drug administration ≤4.5 hb
 Recent head injury or  CT scan showing no
intracerebral hemorrhage or
 hemorrhage  edema of >1/3 of the MCA
 Major surgery in preceding 14 territory
days  Age 18 ≥ years
 Gastrointestinal bleeding in
preceding
 21 days
 Recent myocardial infarction
 Contraindication: Severe  Caution: Patients with
hypotension, cardiogenic aortic stenosis,
shock, left ventricular congestive heart
outflow tract obstruction failure, hypertrophic
(e.g. high-grade aortic cardiomyopathy,
stenosis), heart failure outflow tract
after acute MI. obstruction, severe
obstructive coronary
disease. Hepatic
impairment. Elderly
and children.
Pregnancy and
lactation.
 Contraindications:  Caution: Patient with
Hypersensitivity to dyspepsia or lesion of
aspirin or other NSAIDs. the GI mucosa, asthma
Peptic ulcer, or allergic disorders,
haemorrhagic disease, anaemia, dehydration,
coagulation disorder menorrhagia,
(e.g. haemophilia, uncontrolled
thrombocytopenia), hypertension, G6PD
gout. Severe hepatic and deficiency,
renal impairment. thyrotoxicosis.
Children <16 years and Patients undergoing
recovering from viral surgical procedures.
infection. Pregnancy Moderate hepatic and
(doses >100 mg daily renal impairment.
during 3rd trimester) Pregnancy.
and lactation.
Concomitant use with
other NSAIDs and
methotrexate.

Atorvastatin
Fenofibrate
Humulin R
P-DRUGS
DRUG NAME
Nicardipine IV 5mg/hour
IV rt-PA 0.9mg/kg
Aspirin 325mg/day;
80-100mg PO OD
Amlodipine 10mg OD
Atorvastatin 10-20mg PO OD
Fenofibrate 145mg PO OD
Metformin 500mg PO BID
VI. MONITORING AND FOLLOW-UP
1. Repeat labs: FBS, Lipid Panel and Creatinine
2. BP Monitoring daily
3. Repeat Neurologic exam on follow-up after 1 wk
4. Educate the patient about smoking cessation and moderate exercise and diet for weight loss
5. DASH diet
6. Continue physical therapy
7. Educate patient on medication compliance
VII. PRESCRIPTION WRITING
acid (ASA).  Food interaction:
Increased risk of GI
bleeding with alcohol.
Reduced GI irritation
with admin of food and
large quantity of water
or milk.
 for hypercholesterolemia,  Contraindications: Active  Caution: Patients with
mixed dyslipidemia liver disease, diabetes mellitus,
 Atorvastatin selectively unexplained persistent hypothyroidism,
and competitively inhibits serum transaminase hereditary muscular
HMG-CoA reductase, the elevation. Pregnancy and disorders, recent
enzyme that catalyses the lactation. Concomitant stroke, transient
conversion of HMG-CoA to use with ciclosporin, ischaemic attack,
produce mevalonate. The systemic fusidic acid, severe acute infection,
reduction of mevalonate telaprevir, hypotension, major
production results to a glecaprevir/pibrentasvir surgery, predisposing
compensatory increase in and tipranavir/ritonavir factors for
the expression of LDL combinations. rhabdomyolysis,
receptors and stimulation severe metabolic
of LDL catabolism, disorder and
consequently lowering uncontrolled seizures.
LDL-cholesterol levels. Patients taking
concomitant CYP3A4
inhibitors.
 
 
NOTES COST
slow infusion; BP and heart rate should be monitored carefully esp during initiation
P 1.247.00/amp
of therapy and titration or upward adjustment of dosage.
maximum of 90mg; 10% bolus, 90% for 1 hour infusion
via feeding tube for 48 hours;
P2.80/tab
maintenance dose
BP maintenance P6.25/tab
lipid control P 50.35/tab
lipid control P42.00cap
DM maintenance P 3.75/tab

CASTILLO, RICHELLE ANNE N. CASTILLO, RICHELLE ANNE N.

CASTILLON, CZARINE P. CASTILLON, CZARINE P.
CORSAME, GILCEL ALLIANA L. CORSAME, GILCEL ALLIANA L.
DELA CRUZ, CELINE VENERIA F DELA CRUZ, CELINE VENERIA F
CORSINO, JOVILYN A. CORSINO, JOVILYN A.
CASIANAN, DAYLE DANIELLE S. CASIANAN, DAYLE DANIELLE S.
Silliman University Medical Center Silliman University Medical Center

Patient: L.M. Date: 11/11/19 Patient: L.M. Date: 11/11/19

Address: DUMAGUETE Age/Sex: 67/F Address: DUMAGUETE Age/Sex: 67/F

Nicardipine (Cardepine) IV 5mg/hr via slow infusion #1 rtPA

 Lic. No. 0123456
Lic. No. 0123456 PTR No.:
PTR No.: S2 License No.:
S2 License No.:
CASTILLO, RICHELLE ANNE N. CASTILLO, RICHELLE ANNE N.
CASTILLON, CZARINE P. CASTILLON, CZARINE P.
CORSAME, GILCEL ALLIANA L. CORSAME, GILCEL ALLIANA L.
DELA CRUZ, CELINE VENERIA F DELA CRUZ, CELINE VENERIA F
CORSINO, JOVILYN A. CORSINO, JOVILYN A.
CASIANAN, DAYLE DANIELLE S. CASIANAN, DAYLE DANIELLE S.
Silliman University Medical Center Silliman University Medical Center

Patient: L.M. Date: 11/11/19 Patient: L.M. Date: 11/11/19

Address: DUMAGUETE Age/Sex: 67/F Address: DUMAGUETE Age/Sex: 67/F

Aspirin (Bayer Aspirin) 325mg/day tablet via feeding tube Metformin 500mg taken orally 2x a day #30
for 48 hours;
100mg tablet taken orally once a day for maintenance
therapy

Lic. No. 0123456

PTR No.:
S2 License No.:

Lic. No. 0123456

PTR No.:
S2 License No.:
CASTILLO, RICHELLE ANNE N. CASTILLO, RICHELLE ANNE N.
CASTILLON, CZARINE P. CASTILLON, CZARINE P.
CORSAME, GILCEL ALLIANA L. CORSAME, GILCEL ALLIANA L.
DELA CRUZ, CELINE VENERIA F DELA CRUZ, CELINE VENERIA F
CORSINO, JOVILYN A. CORSINO, JOVILYN A.
CASIANAN, DAYLE DANIELLE S. CASIANAN, DAYLE DANIELLE S.
Silliman University Medical Center Silliman University Medical Center

Patient: L.M. Date: 11/11/19 Patient: L.M. Date: 11/11/19

Address: DUMAGUETE Age/Sex: 67/F Address: DUMAGUETE Age/Sex: 67/F

Fenofibrate (Fenoflex) 160mg capsule Amlodipine 10mg taken orally once a day #30
taken orally once a day #30
 Lic. No. 0123456 Lic. No. 0123456
PTR No.: PTR No.:
S2 License No.: S2 License No.:
CASTILLO, RICHELLE ANNE N.
CASTILLON, CZARINE P.
CORSAME, GILCEL ALLIANA L.
DELA CRUZ, CELINE VENERIA F
CORSINO, JOVILYN A.
CASIANAN, DAYLE DANIELLE S.
Silliman University Medical Center

Patient: L.M. Date: 11/11/19

Address: DUMAGUETE Age/Sex: 67/F

Atorvastatin (Lipitor)
20 mg taken orally once a day #30

Lic. No. 0123456

PTR No.:
S2 License No.: