Case presentation on Acute venous

thrombosis with hypertension and

diabetes mellitus.
NAME: JAHNAVI KAYASTHA
EN.NO: 202002102510031
CLASS: 4TH YEAR PHARM D
MALIBA PHARMACY COLLEGE
Patient information:
• Name : Umesh .K. Kayastha
• Age: 41 Year
• Gander: Male
• Weight: 90 kg
Patient complaint:
• On 24, September, 2018 • On 27, September, 2018
• C/O--- • C/O---
• Perspiration • Perspiration
• Headache • Headache
• Vomiting • Paralysis in left body
• Abdominal pain (after meal • Unable to walk and talk
increases)
• Concious & oriented
Past Medical history:
• Hypertension (12 years)
• Diabetes mellitus (12 years)
• Acute pyelonephritis (10 years)
• Gastric ulcers & chronic gastritis (9 years)
• Fatty liver grade 1 (7 years)
Past medication history:

• Telmisartan + Chlorthalidone (40 mg + 12.5 mg)

• Nebivolol (2.5 mg)
• Metformin hydrochloride + Glimepiride (1000 mg + 2 mg)
• Rabeprazole (20 mg)
• Family hx : His Father diagnosed with hypertension and diabetes mellitus
at age of 40 years.
• His father died due to stroke at age of 68 years.
• His mother diagnosed with hypertension and diabetes mellitus at age of 45 years.
• Social hx : No addiction
• Occupation : Teacher
Vitals:
On 24/09,
• BP: 150/100 mmhg
• Pulse: 95 beats/min
• CNS: concious & oriented
Parameter Date
• SPO2: 96% s
27/09 28/09 29/09 30/09 31/09 01/10
BP 140/100 140/100 120/90 120/90 120/90 120/90
(Mmhg)
Pulse 95 100 95 90 94 90
(Beats/
min)
SPO2 96 97 97 96 96 96
(%)
Provisional Diagnosis:
• From Signs and symptoms we can’t assume any condition in this case
so we have to check lab data and CT brain , MRI brain
Lab data:
Laboratory Dat D Normal
investigation e range
24/09 27/09 28/0 29/09 30/09 31/09 01/10
9
Haemoglobin 14.5 14.6 14.0 13.20 13.10 13.12 13.14 13-18
gm/dl
MCV 75.5 76.0 75.0 74.01 74.0 74.0 76.0 80-96 FL
MCH 23.7 22.5 23.0 22.71 22.70 22.70 22.71 27-33 Pg
MCHC 31.4 30.5 31.0 30.69 30.70 30.50 30.50 33-36
gm/dl
Total WBC 10,000 11,00 10,00 3,500 3,500 3,400 3,500 4000-
0 0 10,000/
cmm
Lab data:
Laboratory investigation Date Normal
range
24/0 27/0 28/09 29/09 30/0 31/0 01/1
9 9 9 9 0
Total RBC 6.12 6.14 6.10 5.81 5.81 5.79 5.80 4.4-5.9
million/c
mm
Band cell 00 00 00 00 00 00 00 0-5%
Neutrophils 65 64 65 70 71 70 72 40-75%

Eosinophils 04 05 05 05 02 02 01 1-6%

Basophils 00 00 00 03 04 03 04 0-5%
Lymphocytes 28 29 30 25 25 20 21 20-45%
Lab data:

Laboratory investigation Date Normal

range
24/09 27/09 28/09 29/09 30/09 31/09 01/1
0
Monocyte 03 03 04 00 02 01 02 2-10%
R.D.W 14.1 14.0 14.0 13.20 13.10 13.11 13.05 11.5-14%
Platelet count 27200 27100 27000 19400 19410 1931 1941 150000-
0 0 0 0 0 00 00 450000/
cmm
PCV 46.2 46.1 46.0 43.0 44.0 43.0 42.5 40-57%
Lab data:

Laboratory investigation Date Normal range

24/09 27/09 28/09 29/09 30/09 31/09 01/10
Fasting blood glucose 181 178 177 158 168 167 157 Upto 140
mg/dl
Lab data:
Laboratory investigation Date Normal range

24/09 27/09 28/09 29/09 30/09 31/09 01/1

0
Homocysteine 26.38 24.00 24.38 20.50 16.00 16.10 16.00 5.46-16.2
Mcmol/L
Sr. creatinine 1.1 1.0 1.0 1.1 1.0 1.0 1.0 0.4-1.4 mg/dl

PT - Time P- 14 s - - - - - -
C- 12 s - - - - - -
PT – Index 86% - - - - - 100% 100%
INR 1.22 - - - - - -
APTT P-28 s - - - - - 28 s 24-34 sec
C-28 s - - - - - -
Other specific tests:
• CT-Brain:
• Hyperdensity in right sigmoid, posterior portion of superior saggital sinuses.
• F/S/O Venous sinus thrombosis.
• Mild Hyperdensity in straight sinus could represent slow flow.
• MRI venography-Brain:
• Lods of flow in right transverse, sigmoid sinuses , right internal jugular vein ,
posterior portion of superior sagittal sinus with GRE blooming. Flow reduction
in straight sinus , high frontoparietal cortical veins.
• F/S/O ACUTE VENOUS THROMBOSIS.
Daily treatment chart:
Drug Indicatio Content Dose Frequency Date
(Brand n (Generic name)
name)
24/ 27 28/ 29/09 30/ 31/ 01/
09 /0 09 09 09 10
9
Tab Pain Tramadol/ 37.5/325 1-0-1 ➖ ➖ ➖ ➖ ➖ ➖
Ultracet killer Acetomenophe mg
n
Tab Antidiab Metformin/ 500/20 1-0-0 ➖ ➖ ➖ ➖ ➖ ➖
Teniva etic Teneligliptin mg

Tab Azulix Antidiab Metformin/ 500/02/0 0-1-0 ➖ ➖ ➖ ➖ ➖ ➖

MV etic Glimepiride/ .3 mg
Voglibose

Tab Warf Anticoag Warfarin 02 mg 0-0-1 ➖ ➖ ➖ ➖ ➖ ➖

ulant
 Drug Indication Content Dose Frequency Date
(Brand (Generic name)
name)

24/ 27/ 28/ 29/09 30/ 31/ 01/

09 09 09 09 09 10
Tab B-complex Vit B12 /B9/B6 400mcg/01/10 1-0-1 ➖ ➖ ➖ ➖ ➖ ➖
Homocheck vitamin mg
supplements

Tab Acid Pantoprazole 40 mg 1-0-1 ➖ ➖ ➖ ➖ ➖ ➖

Pantocid suppressant

Inj Troynoxa To prevent Enoxaparin 60 mg/0.6 ml 1-0-1 ➖ ➖

blood clots

Inj Acticef Prophylaxis Ceftriaxone 1 gm 1-0-1 ➖ ➖

 Drug Indication Content Dose Frequency Date
(Brand
name) (Generic name)
24/ 27/ 28/ 29/09 30/ 31/ 01/
09 09 09 09 09 10
Inj Antiemetic Ondansetrone 2 mg/ml 1-0-1 ➖ ➖
Supracetr
on
Inj Acid Pantoprazole 40 mg 1-0-1 ➖
Pantact suppressant
Inj Emset To prevent Ondansetrone 4 ml 1-0-1 ➖ ➖
nausea &
vommiting
Inj Pain killer Tramadol 100 mg 1-0-1 ➖ ➖ ➖
Contramal
 Drug Indication Content Dose Frequency Date
(Brand (Generic name)
name)
24/ 27/ 28/ 29/09 30/ 31/ 01/
09 09 09 09 09 10
Inj Rado Antiemetic , Domperidone/ 10/20 mg 1-0-1 ➖ ➖ ➖
acid Rabeprazole
suppressant

Inj Pain reliever Diclofenac 75 mg/ml 1-0-1 ➖ ➖ ➖

Gudgesic
AQ

Tab Dolo Pain killer Paracetamol 650 mg SOS ➖ ➖ ➖

 Drug Indication Content Dose Frequency Date
(Brand (Generic name)
name)
24/ 27/ 28/ 29/09 30/ 31/ 01/
09 09 09 09 09 10
Tab Parix Pain Paracetamol 650 mg SOS ➖ ➖ ➖
reliever
Tab Pain killer Tramadol/ 37.5/32.5 SOS ➖ ➖ ➖
Traceta Paracetamol mg

Inj Anticoagu Nadroparin 9,500 IU/ ml 1-0-1 ➖ ➖ ➖ ➖ ➖

Fraxipari lant calcium
ne
Inj Anti Dexamethasone 1mg/ml 1-0-1 ➖ ➖ ➖ ➖
Dexona inflammat
ory
Tab Antihyper Amlodipine/ 05/50 mg 1-0-1 ➖ ➖ ➖ ➖
amloact tensive Atenolol
 Discharge medication:
Drug Content Indication Dose Frequency Quantity/Duration
(Brand name) (Generic name)
Tab. Cefexl Cefixime/ Infection 200/500 mg 1-0-1 5 days
Cloxacillin
Tab. Panta D Domperidone/ Antiemetic,acid 10/40 mg 1-0-1 5 days
Pantoprazole suppressant
Tab. Stabivit Vitamin A Vitamin 500 mg 0-1-0 10 days
supplements
Syr. Tritam Piracetam To treat myoclonus 5 ml 1-0-1 10 days
Tab. Clow flow plus Aspirin/ Antiplatelate 75/75 mg 0-1-0 10 days
Clopidogrel
Telvas-CT Telmisartan/ Antihypertensive 40/12.5 mg 1-0-0 Continue till next
Chlorthalidone visit
Tab. EXERMET GM Metformin/ Antidiabetic 1000/2 mg 1-0-1 ||
FORTE 2 Glimepiride
Nebicard Nebivolol Antihypertensive 5 mg 0-0-1 ||
Tab. Warf 5 Warfarin Anticoagulant 5 mg 0-0-1 ||
Tab. Rosupil Rosuvastatin Lower the lipid 10 mg 0-0-1 ||
Syr. Creamaffin Mg based syrup Constipation 5 ml 1-0-1 ||
Pharmaceutical care plan:

Subjective Data Objective Data

On 24/09,
• CT- Brain
• Perspiration
• Headache • MRI venography-Brain
• F/S/O Acute venous
• Vomiting thrombosis
• Abdominal pain(after meal increases) • BP:150/100 mmHg
On 27/09, • Fasting Blood Glucose:
• Unoriented 181 mg/dl
• Not able to walk
• Numbness on left side of the body
Assessment:
• Acute venous thrombosis with hypertension and Type 2 diabetes mellitus.
Treatment options: (Initial approach)
Treatment options:
Treatment options: ( Thrombolytic
Therapy)
First post stroke visit:
Treatment: (Thrombolytic therapy)
Drug name Dose regimen
tPA 0.9 mg/kg IV; not to exceed 90 mg total dose;
(Alteplase) administer 10% of the total dose as an initial IV
bolus over 1 minute and the remainder infused over
60 minutes.
Antiplatelate agents
Aspirin Initial: 160-325 mg PO within 48 hr of stroke/TIA
onset, followed by 75-100 mg PO qDay
AHA/ASA recommends an initial dose of 325 mg
within 24-48 hr after stroke; do not administer
aspirin within 24 hr after administration of alteplase.
MAINTENANCE (SECONDARY PREVENTION)
Extended-release capsule (Durlaza [Rx]): 162.5 mg
PO qDay
Patient positioning:
• Studies have previously shown that cerebral perfusion pressure is
maximized when patients are maintained in a supine position.
However, lying flat may serve to increase ICP. A cluster-randomized
crossover trial in patients with acute stroke (85% ischemic) showed
that disability outcomes after acute stroke did not differ significantly
between patients assigned to a lying-flat position for 24 hours and
patients assigned to a sitting-up position with the head elevated to at
least 30 degrees for 24 hours. Because prolonged immobilization may
lead to its own complications, including deep venous thrombosis,
pressure ulcer aspiration, and pneumonia, patients should not be kept
flat for longer than 24 hours.
Goals of treatment:
Disease Short term goals Long term goals

Hypertension To relieve symptoms and achieve To minimise the risk of further

the goal blood pressure 140/90 complications like Renal
mmHg. dysfunction, cardiac dysfunction
etc.

Diabetes mellitus To relieve symptoms and achieve To minimise the risk of further
the goal random blood sugar levels complications like neuropathy,
<140 mg/dl. retinopathy etc.

Acute venous thrombosis To relieve symptoms like pain and To minimise further complications
make patient stable. like pulmonary embolism etc.
Goals achieved:
• Patient is stable and symptoms are relieved.
• Target blood pressure is achieved.
• Target blood sugar is achieved.
Monitoring parameters of drugs:
Drug Name Monitoring parameters
Tab. Cefexl LFT, serum K+
Tab. Panta D Sr. Iron level, gastric PH
Tab. Stabivit Blood vitamin A level
Syr. Tritam SPO2
Tab. Clow flow plus Coagulation profile
Telvas-CT Blood pressure
Tab. EXERMET GM FORTE 2 RBS,HBA1C
Tab. Nebicard Blood pressure, heart rate
Tab. Warf 5 Blood clotting time
Tab. Rosupil Lipid profile
Syr. Creamaffin Sr. Electrolyte level
Monitoring parameters of disease:
Disease Monitoring parameters

Hypertension Blood pressure, RFT

Diabetes mellitus RFT , HbA1C , RBS

Acute venous thrombosis CT-Brain , MRI-Brain , Coagulation profile

Patient councelling:
• DRUG BASED:
• Common point: If 1 dose is missed than take it as soon as possible or if it’s
almost time for next dose than don’t double the medication take single dose ,
skip missed dose.
• Don’t crush or break tablet , swallow the whole tablet.
1. Tab. Cefexl – If you mark any symptoms like diarrhoea, abdominal
pain severly instantly consult the doctor.
2. Tab. Panta D – Take medicine before meal and don’t take it with
alcohol.
3. Tab. Stabivit – Don’t take it with alcohol, it can damage liver.
Patient councelling:
• Continue....
4. Syr. Tritam – If symptoms seen like depression, insomnia , weight gain
severly than instantly consult your doctor.
5. Tab. Clow flow plus – In some patients it shows blurred vision so don’t drive
after taking of it.
6. Tab. Telvas-CT – This medication can cause frequent urination so keep your
self hydrated.
7. Tab. Exermet GM forte 2 – keep monitoring on your blood glucose level and
eat adequate meal.
8. Tab. Nebicard – Keep watching on blood sugar levels and heart rate because
it’s effect can mask the symptoms of hypoglycemia.
Patient councelling:
• Continue...
9. Tab. Warf 5 – keep your self safe from getting injured because it is
anticoagulant drug which thin your blood and injury can cause loss of
blood.
10. Tab. Rosupil – Good to take at night time because cholesterol
production is more at night time.
11. Syr. Creamaffin – Take with fibrous food , Warm water to get best
results.
Patient councelling:
• DISEASE BASED:
1. Hypertension – Continuously monitor your blood pressure and keep
medication adherence to maintain good BP.
2. Diabetes mellitus – Periodically monitor your blood glucose level and
every 6 month keep records of HbA1C report.
3. Acute venous thrombosis – It is the condition in which blood of veins
of brain are formed clots due to injury or any other reason, it can be
ischemic or hemmoragic.
• If you notice any symptoms like walking difficulty, paralysis, headache,
perspiration, vertigo Etc. Immediately go to the hospital it could be a stroke
attack.
Patient councelling:
• LIFESTYLE BASED:
• Keep aerobic exercise in routine life.
• Do meditation and stress relieving yoga.
• Add vitamin c reach food to reduce oxydative stress.
• Add vegetables and whole grains in your diet.
• Maintain adequate BMI or weight.
Evidences:
• Increase homocysteine and decreased vitamin B complex relation
with ischemic stroke
Evidences:
• Vitamin A in treatment of strok to prevent brain oedema
Clinical pharmacist interventions:
1. Lipid profile was not performed
2. Prescribed rosuvastatin without considering lipid profile
3. Slight overdose of Tramadol
4. Concomitant use of enoxaparine and fraxiparine can increase
chances of gastrointestinal bleeding tendency
5. Drug without indication: Vitamin A
Intervention based reference:
• Medscape Interaction checker.
• National clinical practice guidelines 2012.
Thank You!!!