Case No.

:
Date:

SUBJECTIVE
PROBLEM

OBJECTIVE
1.VITAL SIGNS

ASSESSMENT
ETIOLOGY OF PROBLEM

PLAN
1.EVALUATE

GOALS FOR

RECOMMEND

2.LAB TESTS

CURRENT

TREATMEN

1. DRUG TREATMENT FOR

3.MED.LIST

THERAPY FOR

T OF

PROBLEM

PROBLEM

PROBLEM

2. MONITORING PARAMETERS

2.EVALUATE

FOR EACH DRUG LISTED

NEED FOR

3. FURTHER TESTS FOR

THERAPY

PROBLEM IF NEEDED

PATIENT
EDUCATIO

4. DRUGS TO BE AVOIDED AND

WHY
Cerebral Vascular Accident

VITALS:

Hemiparesis is weakness of

1. To decrease

(CVA) -

PR: 92/min

the entire left or right side of

the pain on left

the blood

Inj. Piracetam 7.2gm B.D

medication adhere

HEMIPARESIS

B.P: 130/90 mm of Hg

the body. Hemiplegia is its

upper and lower

flow to

Inj. Pantoprazole 40mg O.D

Strengthening the

SPO2 : 98%

most severe form, complete

limbs and

T. Atorvastatin 40mg H.S

and hand muscles

30 y/o Male, was admitted on

CVS : s1 s2 + +

paralysis of half of the body.

prevent the

T. Aspirin 75mg H.S

balance through r

02/04/2014 with c/o

RS: Clear

Hemiparesis and hemiplegia

further attacks

Pain on both left upper limb

ABD: Soft

can be caused by different

CNS: Sensory - Normal

medical conditions, including

Need for

PMH: Deviation of mouth to

RADIOLOGY:

congenital causes, trauma,

Therapy: No

tumors, or stroke

change in

CT BRAIN:
Cranial nerve
examination : Normal
Pupil : Normal

brain.
2. Prevent the
platelet
aggregatio

and left lower limb at 2 O clock

left side

1. Increase

1. Inj. Citicoline 500mg B.D

T. Clopidogrel 75mg H.S

walking and exerc

Inj. Ondansetron 4mg SOS

2. Attend atleast 5

n.
3. Increase
the muscle

1. Continue emph

months programm
2. In case of ondansetron

physiotherapy.

administration we have to

3. Patient should w

therapy is

monitor cardiac function and

flat and wide toed

required.

continuous blood pressure

shoes.

Continue current

check up should be needed.

4. Dont drive or h

Current medication:

therapy to

Inj. Ondansetron 4mg SOS

prevent further

Inj. Citicoline 500mg B.D

TIA and CVA.

rigidity

3. MRI should be done if needed.

4. Piracetam itself may induce
Hemiparesis

the machines whi

using the medicat

because some dru

Inj. Piracetam 7.2gm B.D

cause drowsiness

Inj. Pantoprazole 40mg O.D

5. Pay close atten

T. Atorvastatin 40mg H.S

while walking.

T. Aspirin 75mg H.S

6. Take calcium ric

Department of Pharmacy Practice, Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor-517127 (AP), INDIA

Case No.:
Date:

T. Clopidogrel 75mg H.S

foods and also tak

calcium suppleme

Department of Pharmacy Practice, Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor-517127 (AP), INDIA