Clinical pharmacy I ( practical ) University of Sana'a

Dr. Ashraf Rafeq alammari Pharmacy 5th year

--------------------------------------------------------------------------------------------------------------------------------
Introduction to Practical Clinical pharmacy

Definition :-

Clinical pharmacy is the study of clinical courses that enabled the

pharmacist to participate in medical diagnosis and management
of diseases and apply these skills for patient care .

- Related medical sciences :-

Basic medical and pharmaceutical sciences must be learned,

involving :

Physiology, Pharmacology, Anatomy, Pathology , Microbiology

and Biopharmaceutical and Hospital Pharmacy, etc .

• Guidence Points fo hospital internship / rotation in therapeutic

areas of concern:

1- Knowldege base .

2 – patient contact .

3 – Round

4 – Practice Visit

5 – Drug information and distribution.

6 - Logistic :

7 – Discussion .

1
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------

SOAP notes of Clinical pharmacy

S = Subject (Personnel data + History)
O = Object (Physical examination : Signs & Symptoms +
Diagnostic tool s : Lab data & instruments .
A = Assessment : Diagnosis ,, (based on collected data)
P = Planning : Treatment & therapy Monitoring

2
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
Hypertension
Definition :-

Elevation of systolic and/or diastolic B.P above 140/90 .

B.P = Cardiac output CO X peripheral vascular resistance PVR .

Types and Etiology :-

1- primary hypertension : ( 90 – 95 % of cases )

Unkown etiology (cause) , thought to be related to :

a – Renin- angiotensin – aldosterone system .

b – ANS & Baroreceptor reflex.

2 – secondary hypertension : ( 5 - 10% of cases )

a – Renal disease .

b – Endocrine disorders ( hyperthyroidism , aldosteronism )

c – Medical causes (contraceptive , caffeine , NSAIDs ) .

* Clinical measuring of hypertension HTN

3
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
* How can you measure the B.P ?

- Sphygmomanometer :- 2 to 3 times a day for 5 to 7 days

Then taking <the average > this is called HBPM , or by ABPM.

Old Classification
Normal HTN 120 – 139 / 80 - 99 mm Hg .
Adult : hypertension stage 1 140 – 159 / 90 – 99 mm Hg
Adult htn stage 2 160 – 179 / 100 – 109 mm Hg
Adult htn stage 3 180 – 209 / 110 - 119 mm Hg
Elderly normal range 100/75 mm Hg

Hypertension Risk Factors :

1. Tobacco use 2. over weight.

3. Diabetes mellitus . 4. coarctation of Aorta/ stenosis.

5. stress . 6. Inactivity .

* Uncontrolled risks : Age , Sex , Race and Family history .

Q) What is Pregnancy Hypertension . & its safe control .

4
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
* Hypertension Complications ( Target Organ Damage):-

- Brain stroke : intracerebral haemorrhage (stroke).

- C V S problems : MI , CHF , LVH etc .
- Atherosclerosis :
d/t persistent high pressure on artery wall. plaque.
- Kidney Damage/failure : Glomerulosclerosis .
- Retinopathy : retina hemorrhage (blindness) .

* Clinical Diagnosis & Analysis :-

Initial diagnosis mostly not estimated from patient , as HTN is

asymptomatic disease , rather it is confirmed by BP measurement

Unfortunately BP mostly detected after one or more complication

has been occurred.

5
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
Clinical Analysis : mostly used to confirm HTN complications

• Haematologic tests :

CBC - ESR - FBS - Cholesterol- Creatinine.

• Plasma electrolytes tests: Na+ , K+ , Ca+2 .

• Urine analysis .

• Chest X – ray , ECG & Echocardiogram .

* Treatment of Hypertension :- according to priority

- ACE inhibitors: lisinopril (2.5-5-10mg) OD ,captopril (25mg or

50mg) BID. DOC in majority of Hypertensinve patients.

MOA : block the conversion of angiotensin I to angiotensin II lead

to : V.D ,↓ B.P and decrease aldosterone release

S.E : Dry persistence cough and angioedema , Hyperkalemia and

teratogenicity

- ARBs : Angiotensin receptor blocker :

Candesartan 8 or 16mg , Valsartan 80 or 160mg

Less dry cough,,, Expensive

- Ca+2 Channel Blockers CCB :-

-Selective blocker on cardiac muscle (eg. verapamil) , C/I with β

blockers .

6
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
-Selective blocker on blood vessel , Nefedipine : decrease TPR &
BP , but C/I with Nitrates

- Diuretics :

Thiazides , loop diuretics & spironolactone .

Note:-

- Diuretics mostly used in combinations with other

antihypertensive agent (especially Thiazides)
- Diuretics should be avoided in renal diseases / impairment
except loop diuretics .

- Spironolactone is diuretic of choice in heart disease

- β-Adrenoreceptor blockers :-

propranolol 10–40mg TID or Timolol 10mg BID,,,, non selective , not

used for Asthmatic and COPD patient

Atenolol 50 -100mg, bid or Bisoprolol 2.5mg or 5mg or 10mg once

daily ,, Selective : less bronchospasm effect

S.E : Bradycardia and heart block ,Cold extermities , sexual

dysfunction and sudden withdrawal adverse action .

.- Vasodilator :

- Organic Nitrates :

Nitroglycerin and Isosorbid 5 – 10mg ,in case of Ischemic heart

disease, e.g (Angina)

- Hydralazin : arteriodilator ,,may cause SLE and R.A

7
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
- Sodium nitroprusside Mixed Dilator I.V in emergency .

α1 Adreno-receptor antagonist :
- Phenoxybenzamine , Prazocin

Selective α2 Adreno-receptor agonist :

Clonidine , α -methyldopa

Note :-

HTN with African or elderly Thiazide , CCB

HTN + Pregnancy α Methyldopa , labetalol

HTN + D.M ACEI , CCB

HTN + Hyperlipidemia CCB

HTN + Heart failure Diuertics , ACEI

HTN + Angina pectoris β blockers , CCB

Hypertension for patient older than 55 years old ,, CCB

8
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------

9
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
Case 1 :- hypertension

G.p is a 50 year–old man who is referred to emergency for Evaluation of hi

gh blood pressure . His only complaint is the presence of occipital mornin
g headache .Hypertension was detected four years ago and treated with Wi
ght reducing diet and sodium restriction .He also had a peptic ulcer 10 years
ago

.His father had hypertension and died of heart attack at age 59 .His moth
er died of stroke at age 62 and was an insulin dependent diabetic. He has a
20 year history of cigarette smoking. He believe his evaluated blood pressu
re has been caused by anxiety over his recent loss of employment. On phys
ical examination his height 175 cm and his weight was 107 Kg .

His blood pressure was 170/120 mmHg ,his pulse was 75 beats /minute .fun
duscopic examination revealed mild arteriolar narrowing sharp disks and
no exudates or hemorrhage .

laboratory examination revealed the following: serum electrolytes within

normal limit ,BUN 30mg/dl (8- 25 mg/dl), serum creatnine 2mg /dl(0.6 –
1.5 mg/dl) ,serum uric acid 12mg/dl (3-7 mg /dl) , serum glucose 90 mg/d
l(70- 110mg/dl) ,hemacrit 42 %(45 -25%) and mildly elevaezted fasting cho
lesterol and triglyceride. Urinalysis reveled one plus (+)

Electrocardiogram and X-ray revealed mild left ventricular hypertrophy .

1. What are symptom of essential hypertension ?

2. What are major organ of the body adversely affected by hypertension .and how c
an these adverse effect be monitored ?

3. What are the major cardiovascular risk factor , which predispose toward
hypertension or enhance the risk of M. I generally and in this patient ?

4. What education about hypertension should be given to this patent ?

5 .. Write about the planning of treatment .

10
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
Case 2

Mr PT, a 35-year-old man, is overweight and has a blood pressure

of 178/108 mmHg. He smokes 25 cigarettes daily. He has a sedentary

occupation. He eats excessive quantities of saturated fat and salt.

Mr PT subsequently stopped smoking and lost some weight but

remained hypertensive. He was treated with atenolol 50 mg daily.

His blood pressure fell to 136/84 mmHg, but he developed tiredness

and bradycardia and complained of erectile impotence.

Questions

1. How should Mr PT be managed?

2. What are the treatment options for Mr PT?

11
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
Case 3

ABC is 60 years old sale man in drug company who smoke 1 pack
Cigarettes per day ,but not consuming alcohol.
a known case of hypertension since 10 years. He is on Lisinopril, his BMI is
27kg/m2 ,His both parent died prematurely of CVD,
Medical and disease history is not contributory except peptic ulcer since two
months, treated with sodium bicarbonate containing anti-acid.
On physical examination revealed the following data :
- Blood pressure 155/105mmHg , HR=76 beat per minute, RR = 18breath/m
RR( respiration rate = 18 breath per minute)
- Occipital headache usually in morning
- On inspection to fundoscopy the retina show aneurysm ( disk spot )
On laboratory data
- Echo revealed/show LVH (left ventricular hypertrophy)
- Serum sodium is 140mg/dl (135- 145mEq/L)
- Serum Potassium : 4.9 mEq/l (normal 3.5- 5mmol/L)
- Creatinine test : 2.3mg/dl normal range (0.5 – 1.3mg/dl)

Questions :
Q1 : According to B.P reading in this case ,what is the stage of ABC’s
hypertension
Q2 :What is target blood pressure (how much you will lower the blood
pressure) in this patient .
Q3 :Comment(write your notes)on antihypertensive drug management.
Q5 : What finding of this patient consistent)‫ (توافق‬with the occurrence of
hypertension complication (Target organ damage) .

12
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
Angina Pectoris
Definition :-

Chest pain caused by transient myocardial ischemia.

Concept :-

Supplying the heart by the O2 and nutrient (energy) through blood is by

mean of the coronary arteries – which raised from the base of Aorta.

Angina pain is due to either less blood supply d/t Plaque ,or increased O2
demand as in heavy exercise .

*Pain of angina / MI is :-

Sudden , Severe , pricking chest pain radiating to the neck , jaw

back and arm ,mostly to left side

Other causes of chest pain :- pericarditis , reflux oesophagitis , pleuritis, ribs.

13
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
Types of Angina :-

Stable angina Unstable angina Variant angina

Cause Atherosclerosis Cholesterol plaque

Coronory
Vasospasm .
Occurrence (1-5 to 30 sec.) on (several minutes) At At rest b/w
Exertion , emotion rest , midnight and early
or Little exercise . morning
Relief Decreases at rest Not relieved by rest Relieved by
& relieved by oral or oral medicine. medicine
medicine
* Angina risk Factor:

1. High cholesterol level & fatty diet . 2. Smoking 3. Atherosclerosis.

4. Hypertension . 5. Diabetes .

* Diagnosis

Angina mostly not detected by physical examination. rather, the diagnosis

is clinical .

1. ECG : ST segment depression intially & T wave inversion ( –ve ) .

2. X – ray 3. Coronary angiography.

4. Troponin & CKm-b Enzymatic tests : ( if heart attack is suspected )

14
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
Classification of treatment

* Life style modification :

- Avoid fatty diet & smoking & stress .

- Treat hypertension & hyperlipidemia & DM .

*Anti anginal drugs :

For acute attack :-

Organic nitrates :,as aerosol or sublingual.

Nitroglycerin 0.4mg , Isosorbide dinitrate

Act as vasodilator; more on preload (venous V.D) decrease preload & O2 demand .

MOA of Organic Nitrate :

Stimulate guanylate cyclase to increase cGMP → ↓ Ca+2 influx

lead to vasodilation ,

S.E of Nitrate :- throbbing headache , postural hypotension , flushing

reflux tachycardia , Metemoglobin & Tolerance .

Treatment of Chronic Stable angina :-

1-β-Adrenoceptor blockers : high effective in stable angina : as Cardiac

inhibition (decrease the heart effort): Atenolol , diuretics may added later.

2- Ca+2 Channel Blockers :

Selective blocker on blood vessel , Nefedipine : decrease TPR & BP , , but

C/I with Nitrate, or PDE5 inhibitor (Sildenafil) → Severe hypotension
&reflex tachycardia .

15
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
3- Long acting Nitrate :-

Oral SR (2.5 – 12.5mg) and Isosorbide Mononitrate (10-20mg)

4- New antianginal drugs :-

Nicorandil (5,10&20mg) : use in combination with other antiangial drugs

MOA : 1-K ATP channel opener lead to hyperpolarization,indirectly

inactivate voltage gated Ca+2 channel

2-Stimulate guanylate cyclase to increase cGMP lead to V.D as nitrate .

S.E : Mouth ulcer ,anal ulcer ,palpitation

Ranolazine 500mg :

MOA :block sodium dependent calcium channel

S.E : prolonged QT interval → Ventricular arrhythmia

(Q:What are the Drug Drug interaction with Ranolazine ,e.g with
ketoconazole)

5- Antiplatletes : Aspirin 75mg -81mg – 100mg

Dipyridamole act as thromboxane A2 inhibitor and V.D

Clopidogrel , Ticagrelor ..

6- Antihyperlipidemia : Statins

Note; CCB :-

Selective blocker on cardiac muscle (eg. verapamil) , C/I with β blockers .

Selective blocker on blood vessel , Nefedipine : decrease TPR & BP ,

synergize β blockers, but C/I with Nitrates …. Severe reflex tachycardia .

[Diltiazem] : effective in all types of angina act on both .

16
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
Case study of angina - 4 -

G.H is 75 years old male ,was hospitalized to evaluated his chest

pain ,he is complaining of heavy squeezing sternal chest pain

that radiated to the left shoulders and arm during excretion, his
weight is 225 pounds ,and hypertension for 7 years ago , smoking
20 years ago, His father died of heart attack .

His cholesterol and triglyceride were elevated ,and during his

exercise (Stress ECG test) the ST Segment depression appear after
4 minutes ,the chest pain respond well to Nitroglycerine .

1-What subjective data in this patient

2- Mention the diagnosis of this patient ?

3- What the etiology (risk factor)of patient ?

4- What's advice should be given to this patient ?

5- What are the mechanism of action of nitroglycerine?

6 -What are the diagnostic analysis for angina

17
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
Myocardial Infarction
Definition :-

It is a myocardial necrosis (irreversible tissue death) due to occlusion or

thrombosis of the coronary artery .

Saving Quality of Life :

All patient being transferred to hospital for Chest pain should be managed
as if the pain is ischemic in nature. Unless proving other cause .

Each second is life saving, from onset of ischemic attack, and make the
urgent recovery easier & lessen further complications.

* Symptoms of MI :-

1- Chest pain :-

severe substernal chest pain , radiating to the neck , left shoulder last for
long time & does not relived by rest or nitroglycerin .

2- Unique Symptoms-:

Differ in occurrence among individuals :range from (absent-some -all).

pallor , sweating , dyspnea ,rapid and weak pulse & hypotension.

* MI Complications :-

Pain shock , arrhythmia , heart failure , cardiac arrest .

Types:-

ST segment Elevation Myocardial Infarction : STEMI & NSTEMI.

*Other classification :

Type 1 : Plaque rupture MI. Type 2: d/t Spasm .

Type 3 : Sudden arrest Type 4,5 : PCI , CABG

18
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
*MI Risk Factors :

1. Tobacco use 2. over weight. 3. D.M .

4. Hypertension . 5. stress . 6. Inactivity .

Uncotrolled risk factors : Older age , family history , Male gender .

* Clinical Diagnosis & Analysis :-

Physical observation & findings (as in the previous symptoms), serial ECG ,
Cardiac biomarkers: Troponin T , CK-MB , X –ray ,Echo , angiography .

 Treatment : …..… MONA

1-Morphine Inj ,stat . to relieve the pain

2- Oxygen if Po2 < 90% Oxygen oximetry .

3- Nitroglycerin : spray or sublingual .

4- Aspirin;300mg PO , Clopidogrel 600mg plavix PO (4 or 8 tab) , then

1 tab daily .

5- Alteplase- Streptokinase - urikinase mostly effective after ( 1 to 24 hrs; from

onset of attack .)

1.500,000 iu iv infusion over 1hr ,thrombolysis .

But C/I : in ulcer bleeding , stroke , intracranial tumor , pregnancy, not repeated before 96 hrs .

Heparin : can be given 2ml /hr . 1ml = 5000 i.u. ( i.v or s/c ).

 DRUGS FOR CLOT PREVENTION

Wafarin

Simvistatin : zocor 20 or 40 mg. od or more

* Coronary artery angioplasty : ↓

19
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------

,,

Late Management :-

→ Lifestyle modification: Get out of risk factors.

→ Therapy for DM & HTN ,if present.

* cardiac rehabilitation program.

20
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
Case 5

Mohammed Hasan , a 65 year old male patient from sanaa , known case of
diabetes since last 12 years & coronary artery disease for last 2 years
presented in Althawra hospital with complaints of chest pain radiated to his
arm & neck ,and breathlessness for last 6 hours . patient had an episode of
vomiting, he was conscious and well oriented.

1- Get the patient Profile data .

2- Write the main symptoms of the patient ?

3- What is the pathological events of his previous illness & how can these
diseases affect his life quality ?

4- Write the sequence of clinical data & analysis to get correct diagnosis.

5- By performing the required investigations , the ECG show elevated ST

segment and , raised Troponin test .the patient now entered ICU unit , what
is the first therapy procedure for life saving .

6- What are the types of MI ?

7- What are the precipitating factors of MI in this patient >

8- Write the proper medications for this patient , also late management .

--------------------------

21
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
Case 6 of M.I

B.F is a 54 years old ,54 kg female arrived at the hospital complaint of sever
substernal chest pain that felt like a heavy weight on her chest ,radiating
to her left elbow accompanied by sweeting ,and nausea the pain persisted
for one hour depsit taking 5 nitroglycerine tablets .(about six months prio
r to admission she had substernal chest pain and diagnosis as angina pecto
ris that was treated with sublingual nitroglycerine and oral isosorbide
di-nitrate ) . In the ambulance her blood pressure was 115/85 mmHg . and
her heart rate was 75/min .She arrived at the hospital about three hour
after her chest pain began .

B.F has no past medical history of diabetes or hypertension .She had 20

a pack-year smoking history .Her mother died at age of 68 of cerebrovascul
ar accident (stroke)

her 78 –years old father has history of tow myocardial infraction.

In the emergency room B.F blood was 110/80 mmHg .and H.R 80/min An
ECG reveled ST-segment elevation ,and T-wave inversion .because she was
very anxious about her chest pain ,she was given diazepam 10mg i.m and
transferred to the coronary care unit , where she got morphine sulphate
4mg i.v to control her chest pain .the chest pain continued and she was giv
en morphine 8mg i.v 15 mint later .

After 20 min after the second morphine injection her H.R was 65 /min , her
Bp= 90/75 .and her pain was gone .Other medication include lidocaine 100
mg i.v followed by 2mg /min infusion ,diazepam 5mg po q6h ,and calcium
240mg qd .

On the second day of her hospital stay the patterns of ECG change confirm
ed the diagnose of acute myocardial infraction . Her cardiac enzyme conc
entration CPK (CK-MB ,SGOT and LDH were elevated . the lidocaine infu
sion was discontinued after 48hour , and no arrhythmias accrued during
the four days she was in the coronary care unit .

22
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
Question

1. What subjective and objective evidence is compatible with diagnosis

of M.I in this patient ?

2. .Why was B.F given morphine sulphate ,were the route and dose app
ropriate ?

3. What is the goal of morphine therapy , how should she be managed

if the pain not relived ?

4. If B.F was unable to tolerate morphine, what alternative analgesic co

uld be used?

5. Are there any analgesic which are contraindicated in M.I ?

6. The patient received 10mg diazepam i.m in the emergency room ,wh
at evidence support the use anxiolytic agent like diazepam in routine
management of acute M.I ?

7. Is the route of diazepam appropriate ?

8. B.F .was not given any anticoagulant during hospitalization .what ar

e the indication of anticoagulant after an acute M.I?

23
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
Stroke

Definition :-

Stroke :- occurs when the blood supply (of oxygen and nutrients) to part of your
brain is interrupted or severely reduced . Within minutes, brain cells begin to die .

A stroke is a medical emergency. Early treatment can minimize brain damage

and potential complications.

*Symptoms:-

The length of time the symptoms have been present may guide your treatment
decisions:

 Trouble with speaking and understanding.

 Paralysis or numbness of the face, arm or leg, especially on one side of

your body.

 Trouble with seeing in one or both eyes.

 Headache : sudden, severe headache, which may be accompanied by

vomiting, dizziness or altered consciousness.

 Trouble with walking: loss of balance or loss of coordination.

24
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
*Types :-

1-Ischemic stroke: 85%

 Thrombotic stroke. A thrombotic stroke occurs when a blood clot

(thrombus) forms in one of the arteries that supply blood to your brain.

 An embolic stroke : occurs when a blood clot is come from another place, out
of the brain .

2- Hemorrhagic stroke:-

 a- Intracerebral hemorrhage.

Hemorrhagic stroke occurs when a blood vessel in your brain leaks or bursts
/ruptures. Due to HTN or Anticoagulants .

*A less common cause of hemorrhage is the rupture of an abnormal tangle of thin-walled blood
vessels (arteriovenous malformation) onset at birth.

 b- Subarachnoid hemorrhage. aneurysms at subarachnoid artery, an artery

on or near the surface of your brain bursts causing hemorrhage by spilling
into the space between the surface of your brain and your skull. oftenly
signaled by a sudden, severe headache.

*Note ;aneurysms:-

the bursting of a small sack-shaped or berry-shaped out pouching on an artery.

3-Transient ischemic attack : (TIA)

A transient ischemic attack (TIA) — also known as a ministroke -. A temporary

decrease in blood supply to part of your brain causes TIAs, which often last less
than five minutes.

25
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
Seek emergency care even if your symptoms seem to clear up. Having a TIA
puts you at greater risk (40%) of having a full-blown /entire stroke, causing
permanent damage later.

Risk factors :-

- Obesity - Physical inactivity.

- illicit drugs :such as cocaine and methamphetamines

- Hypertension .

- Smoke. - High cholesterol. - Diabetes.

- Obstructive sleep apnea - Cardiovascular diseases.

Other factors :- include:

 Being age 55 or older.

 Race — African-Americans have a higher risk of stroke than do people of

other races. black have higher rate of death : double

 Gender — Men have a higher risk of stroke than women.

* Complications:-

A stroke can sometimes cause temporary or permanent disabilities, depending

on how long the brain lacks blood flow and which part was affected.
Complications may include:

 Paralysis or loss of muscle movement; Physical therapy may help .

 Difficulty talking or swallowing :- (dysarthria) (dysphagia) (aphasia)

 Memory loss or thinking difficulties.

 Emotional problems.

26
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------
 Pain : lose feeling in your left arm & tingling sensation .

 Changes in behavior and self-care ability.

How is a stroke diagnosed?

Strokes happen fast and will often occur before hospitalization , it should be treated

within 3 hours of occuring.brain scan is the confirmed differentiated test .

1 – Physical Examnation : symptoms and medical history

(measuring blood pressure,retinopathy , auscultation to carotid artery : plaque?)

2 - Blood tests:- Bleeding time (1-4 min), prothrombin time , PT(10 -14 sec).

3 - CT scan: - a series of X-rays that can show hemorrhages, strokes, tumors.

4 - MRI scan - radio waves and magnets create an image of the brain to
detectdamaged brain tissue.

5 - Doppler ultrasound :- u/s for carotid artery to see if there is any plaque
present.*

6 - Cerebral arteriography :- dyes are injected into the brain's blood vessels to
make them visible under X-ray,to visualize the brain and neck blood vessels.

* ECG :- to check for any sources of clots , that could have traveled to the brain
to cause a stroke .

27
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------

Treatments for stroke :-

May the treatment which are suitable for one kind of stroke can be harmful to

someone who has had a different kind.

28
 Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------

Ischemic stroke treatment :- break down clots .

1- Anti-platelet ; Aspirin can be given,

2- (TPA): Tissue plasminogen activator an injection of TPA is very effective at

dissolving clot within 4.5 hours of stroke symptoms starting .

3- Anticoagulants. These drugs include heparin and warfarin .

 There are other procedures that can be carried out :

A carotid endarterectomy Mechanical thrombectomy for stroke

involves a surgeon opening the carotid artery and removing any plaque that
might be blocking it. Or Angioplasty if the stroke is embolic.

Hemorrhagic stroke treatment :-

Focuses on controlling the bleeding and reducing the pressure on the brain.. If
the patient is taking blood-thinning anti-coagulants or an anti-platelet medication
like Warfarin or Clopidogrel, they can be given drugs to counter the medication's
effects or blood transfusions to make up for blood loss.

Prevention :

Life style modification + opposes the risk factors .

29
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------

30
Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
--------------------------------------------------------------------------------------------------------------------------------

A Case of Stroke :- 7

* Optimizing Management and Vessel Imaging study :-

An 83-year-old woman with a history of hypertension and dyslipidemia

developed acute onset of impaired speech ,and right-sided weakness. Her
previous medical history was notable for hyperthyroidism and a curative remote
mastectomy for breast cancer. The patient was on two antihypertensive
medications and a statin, and she was not receiving any antiplatelet medication.
She was taken by ambulance to a primary stroke center. Initial examination
showed global aphasia, right hemianopia, right hemiplegia/paralysis, and
hemisensory loss.

1- Write the Physical examination findings / symptoms .

2 – laboratory blood tests ; PT = 9 sec. Give the significance of this value .
3- Diagnosis by Non_contrast head CT scan& brain MRI scan confirm an Acute
ischemic stroke caused by distal left internal carotid artery occlusion, what are
the precipitating factors leading to acute ischemic stroke ?
4- rescue mechanical thrombectomy using the clot retrieval device,Is this
procedure is preferred ?

5- what are the medications and treatment should be given for this
patient?

6- what is the meaning of TIA , and its risk & prevention .

------------ -------------

31