case presentation on cervical spondylosis by naveen

CASE PRESENTATION ON CERVICAL SPONDYLOSIS

DEPARMENT OF PHARMACY PRACTICE , NIPS 1

PRESENTED BYR.NAVEEN13CD1T00251V PHARM.D

CONTENTS

SUBJECTIVE

OBJECTIVE

ASSESSMENTI

PHARMACEUTICAL CARE PLAN

DISCHARGE MEDICATION

MONITORING PARAMETERS

PATENT COUNSELLING


SUBJECTIVE

A 70yrs old Female patient was admitted in the

hospital with chief complaints of

Giddiness since 20 days

Neck pain assciated with headache

Palpitation

Dragging pain at right lower limbs

PMH: HTN


OBJECTIVE VITALS:

B.P :130/90MM of HG

P.R :110BPM

R.R :16CPM

TEMP: NORMAL

SPO2 : 97%


LABORATORY INVESTIGATIONS

HAEMOGRAM


TESTS RESULT NORMAL VALUE

WBC 11,900cells/cu mm 4400-11,300

RBC 3.8 cells/cu mm 4.5-5.1 cells/cu mm

Hemoglobin 8.8gms/dl 12.5-16.5gms/dl

Sr.Na 125mmol/l 135 to 155 mmol/l

LIVER FUNCTION TESTS

Total protein - 6.1gm/dl (6.3-8.7)

Albumin - 3gm/dl (3.2-5.3)

Globulin - 3.1gm/dl (1.8-3.6)


MRI BRAIN REPORT

Age related diffuse cerebral and cerebellar atrophy micro

angiopathic changes in bilateral coronal radiata and

periventricular white matter

ECHO Cardiogram reports

Moderate LVH


ASSESSMENT

Based on subjective and objective evidences patient was

diagnosed as

EPISODIC VERTIGO , CERVICAL SPONDYLOSIS

Old case of HTN


PLAN

DRUG GENERIC NAME DOSE ROUTE FREQUENCY

I.Nootropil Piracetam 15cc IV TID

I.Pantin Pantoprazole 40mg IV OD

T.Deplatt A clopidogrel_+aspirin 75mg ORAL OD

I.Rosular Rosuvastatin 20mg IV BD

T.Zeevert Betahistine 16mg ORAL BD


DAY-2 VITALS :

B.P : 130/80 mm of Hg

P.R : 80BPM

R.R : 16CPM

TEMP : NORMAL

spo2 : 100%

C/O : Giddiness , body pain .


Sr.Na 128mmol/l 135 to 155 mmol/l

DAY 2

DRUG GENERIC NAME DOSE ROUTE FREQUENC

Y

I.Nootropil piracetam 15cc IV TID


T.Deplatt A Clopidogrel+Aspirin 75mg ORAL OD




Day-3Vitals

B.P : 130/90mm of HG

P.R : 112bpm

R.R : 16CPM

SPO2 : 100%

C/O : Conscious and Better feeling

On this day continue the same therapy .


Day-4Vitals


P.R : 106bpm

R.R : 16CPM

SPO2 : 100%

C/O : Giddiness ,Ab.pain,pain at both gluter at

region


DAY 4

DRUG GENERIC NAME DOSE ROUTE FREQUENCY

I.Nootropil piractem 15cc IV TID


T.Deplatt A Clopidogrel + aspirin 75mg ORAL OD



I.Ativan Lorazepam 2mg ORAL OD

Syp.Duhalat Lactulose 5ml ORAL


Day-5Vitals


P.R : 101bpm

R.R : 18CPM

SPO2 : 98%

C/O : Giddiness , Feeling better


DAY 5

DRUG GENERIC NAME DOSE ROUTE FREQUENC

Y

I.Nootropil Piractem 15cc IV TID


T.Deplatt A Clopidogrel+ aspirin 75mg ORAL OD




Syp.Duhalat Lactulose 5ml ORAL

I.Oflox Ofloxacin IV BD

Oint.Smuth


PHARMACEUTICAL CAREPLAN

SUBJECTIVE OBJECTIVE

A 70yrs old Female patient was admitted in the hospital with chief complaints of

Giddiness since 20 days

Neck pain asscoiated with headache

Palpitation

Dragging pain at right lower limbs

MRI-BRAIN REPORT

Age related diffuse cerebral

and cerebellar atrophy micro

angiopathic changes in bilateral

coronal radiata and

periventricular white matter


FINAL DIAGNOSIS From the above subjective and objective evidences the

final diagnosis was made


EPISODIC VERTIGO ,

CERVICAL SPONDYLOSIS

DISCHRGE MEDICATIONDRUG GENERIC NAME ROUTE DOSE FREQUENCY


T.Deplatt A Clopidogrel+ aspirin 75mg ORAL OD




Syp.Duphalat Lactulose 5ml ORAL


DISEASE MONITORING PARAMETERS

Monitor for oxygen levels

Monitor blood pressure

Monitor blood glucose levels

Monitor body temperature


DRUG MONITORING PARAMETERS

ASPIRIN: Bleeding

ATORVASTATIN: Monitor creatine kinase periodically and LFT


PATIENT COUNSELLING

Some of the steps to take to be healthier and reduce risk

of cervical spondylosis:

Improve your eating habits. Eat foods low in saturated fat,

trans fat, sodium and added sugars.

Hot and Cold compresses.

Regular exercise.

Maintain a healthy weight.

Decrease your stress level.


Eat moderate amounts of food and cut down on saturated

fat, trans fat, sugar and salt.

Take your medicine as directed.

Have regular medical checkups.


REFERENCES Joseph T. dipiro ,Pharmacotherapy A Pathophysiologic

Approach 7th edition.

Roger walker , clinical pharmacy and therapeutics 4th edition.

http://www.nhs.uk/Conditions/Parkinsons-disease.

American Academy of Neurology Guidelines.


THANK YOU


Health & Medicine

case presentation on cervical spondylosis by naveen