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Patient Name: Md Rodzi bin Ismail, 55 years, Male Underlying: DM ( not compliant to Jardiance and Diamicron , Dyslipidemia, Ischemic dilated cardiomyopathy 30/5/2026 2 pm Wide found patient lying unconscious in room, giddiness and fell down around 2.05 pm, left side body weakness. Went to KMC and performed plain CT brain and got results aroyund 4.38 pm indicatrinf suggestive of acute right MCA infact, right frontal encephalomalacia and gliosis and pansinusitis. At 5.40 pm, T. Co Plavix 1/1 STAT , T. Lipitor 40 mg STAT given GCS full, pupil reactive, , left facial asymmetry, slurring of speech, power left: ⅕, right 5/5, ECG: SR, sensation intact, DXT: 154, BP: 144/181, HR: 87 Went to Hospital Sultanah Bahiyah (HSB) ED at 7 pm GSC: E3V4 (Slurred) M6 Tachypneic, obey simple command, + right eye dropping, + left facial asymmetry, SPO2 under RA: 80%, under FMO2 5L/min is 89% and 97% under HFM, Lungs: crepitations over Left side, CVS: DRNM, PA: soft, non tender Reviewed in ward 31/5 O/E: GCS: E3V1M6, DXT: 13, Lungs: bibasal creps, BP: 115/69, PR: 110, T: 37, SPO2: 96% under FMO2, no pedal edama, no gag reflex, moving right upper and lower limb, unable to fully assess neuro, ? delirium Impression: Acute right MCA infarct with left hemiparesis and aphasia NIHSS 12, aspiration pneumonia, decompensated heart failure with underlying dilated cardiomyopathy Iv pantoprazole OD 31/5 8 am S/C actrapd 10 U STAT 2.25 am Plan: Off IV drip Insert RT and start RT 50 cc/ 3 hourly Continue IV augmentin DXt QID T aspirin 150 mg OD T atorva 40 mg ON S/C Actrapid 6U PRN if DXT >12 IV Lasix 20 mg STAT and BD (KIV off cm) Syrup lansoprazole 30 mg BD Wean under NPO2 cm 1/6/2026 Under HFM BP: 116/ 65 Not tachypneic PR: 115 T: 37 SPO2: 97% E3, V1, M6 Lungs: Bibasal creps DXT: 12 Plan: Continue RTF 100 cc/3 hourly IV Augmentin Trace culture DXT QID S/C Actrapid 6U PRN if DXT >12 I/O chart Continue IV lasix Wean down to NpO2 (> 95%0 CT brain if GSC drop ECHO inpatient CT angio 2/6/2026 9.10 am O/E: E4V1M6 Left sided: 0/5 Lungs clear CXR: pneumonia patches No AF, ECG: SR Plan: Repeat CT brain Trial off HPO2 SC insulatard 10 U STAT and BD RTF 150 cc 3 H, 200 cc x 3, then 250 cc x 2 Continue augmentin Start t metformin 500 mg BD STAT and BD 2/6/2026 4.35 pm The repeated CT brain shows small punctuate with mass effect Plan: IV mannitol 200 mg STAT and 100 mg TDS 2) WH aspirin Stated that it can cause cardiorespiratory arrest which requires intubation with 3 expected outcomes: which is best outcome, worsening condition, or prolonged ventilation and need for tracheot?? (unable to read) May also develop cardiac arrest and need for CPR indication . Faimly are indecisive . waiting for another members input 2/6/2026 8.45 pm Patient desat from NPO2 SPO2 -> 88-89% now requiring HFMO2 Upon review HFMO2: O/E: E4V1M5, pupils reacted, BP: 120/76, PR: 146, T: 37, SPO2: 98 %, DXT : 17 (repeated 23.1 ?? Unreadable) , ketone 1.6 Lung transmitted sound Plan: Refer neurological for massive cerebral infarc with hemorrhagic (KIC craniectomy) Awaiting for family decision W/H RT feeding and to NSM? W/H metofrmin and S/c insulin Start S?C insulin sliding scale 6 IV drip 30 NS/24 H IV drip 10 NS/ 4 H DXT 4 hourly Insert new branula Right decompressive craniectomy 2/6/2026 11.30 pm After discussing with family regarding the option of right decompressive craniectomy, family not keen for surgery, cpr, intubation, only wants best medical therapy Plan: Best medical therapy T Neurosurgical input Continue HFMO2 , keep SPO2> 95% Continue IV drip Continue NBM with DXTH? And insulin sliding scale KIV morphine if patient restless and tachypneic 3/6/2026 9.20 am Currently: desaturated yesterday on HFMO2, family input noted, keen for conservative management O/e: pupil equal but not reactive , 2 mm BP: 121/77 PR; 127 T: 37 SPO2: 99% DXT: 6.7 Lungs: clear anteriorly Plan: S/c insulatard 10 U STAT, then BD< Off insulin sliding scale Resume RTF IV mannitol 100 mg TDS for one day then stop STart RTF 200 cc/ 3 H Off IV drip Off cardiac monitor In event of desaturation, not for inotrope, intubation or cpr ECHO inpatient as planned Restart aspirin 4/6 2026 9.20 am Issue: Right MCA infarct with midline shift mass effect (conservative ma nagement) Aspiration pneumonia Uncontrolleld DM AKI? ARI? Currently, Afebrile, no destauration under HFMO2 Following RTF 200 cc/3 hourly O/E: E3, V1, M5 , moving R side of body BP: 133/85 T: 37 SpO2: 100% under HFMO2 DXT:11.8 Explained to caregiver regarding current condition having huge stroke causing mass effect. The likelihood of vegetative state is high. Patient caregiver keen to bring to aurlius hopital but already explained that [atient is already on day 5 of stroke and the management will most likely be the same. Also negated regarding the neurological input, understood they will contact the aurelius hospital first Plan: 1)Trial of VMo2 60% 2) Increase insulatart to 14 U BD 3) Increase RTF to 250 cc/ 3 hourly 4) DXT QID 5) awaiting family decision regarding transfer to aurelius hospital 6) for inpatient echo (TRO LV thrombus) 7) continue IV augmentin 1/52 8) off iv manitol (completed)

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Here are formal daily progress notes covering the entire admission, written in standard clinical format:

DAILY PROGRESS NOTES

Patient: Md Rodzi bin Ismail Age/Sex: 55 years / Male Underlying Conditions: Type 2 Diabetes Mellitus (non-compliant - Jardiance & Diamicron), Dyslipidaemia, Ischaemic Dilated Cardiomyopathy

30/05/2026 - Day 0 (Onset / KMC & HSB ED)

Subjective: Patient found unconscious at home at approximately 1405H by wife. History of sudden onset left-sided body weakness, giddiness, and fall. No prior warning symptoms documented.
Objective (KMC ~1640H):
  • GCS: 15/15 (Full)
  • Pupils: Reactive bilaterally
  • Power: Left 1/5, Right 5/5
  • Left facial asymmetry, slurring of speech
  • Sensation: Intact
  • BP: 144/181 mmHg | HR: 87 bpm
  • DXT: 154 mg/dL
  • ECG: Sinus rhythm
  • CT Brain (Plain): Suggestive of acute right MCA infarct; right frontal encephalomalacia and gliosis; pansinusitis
Treatment at KMC (1740H):
  • T. Co-Plavix 75/100 mg 1 tab STAT
  • T. Lipitor 40 mg STAT
Objective (HSB ED ~1900H):
  • GCS: E3V4(slurred)M6
  • SpO2: 80% on room air; 89% on FMO2 5L/min; 97% on High Flow Mask (HFM)
  • Tachypnoeic; obeying simple commands
  • Right eye ptosis noted
  • Left facial asymmetry persists
  • Lungs: Crepitations over left side
  • CVS: Dual rhythm, no murmur
  • Abdomen: Soft, non-tender
Assessment: Acute right MCA infarct with left hemiparesis and aphasia. Hypoxia likely secondary to aspiration. Background ischaemic dilated cardiomyopathy.
Plan:
  • Supplemental oxygen via HFM; titrate SpO2 >95%
  • Monitoring, IV access
  • Admission to ward for further management

31/05/2026 - Day 1 (Ward Review)

Subjective: Patient reviewed in ward. Unable to verbalise. No fever reported.
Objective:
  • GCS: E3V1M6
  • BP: 115/69 mmHg | PR: 110 bpm | T: 37.0°C | SpO2: 96% on FMO2
  • DXT: 13 mmol/L
  • Lungs: Bibasal crepitations
  • Abdomen: Soft
  • No pedal oedema
  • No gag reflex
  • Moving right upper and lower limbs
  • Neurological assessment limited - ?Delirium
Impression:
  1. Acute right MCA infarct with left hemiparesis and aphasia - NIHSS 12
  2. Aspiration pneumonia
  3. Decompensated heart failure with underlying dilated cardiomyopathy
Plan:
  1. Off IV fluid drip
  2. Insert Ryle's tube (RT) - commence RT feeding 50 cc/3H
  3. Continue IV Augmentin (Co-amoxiclav)
  4. DXT monitoring QID
  5. T. Aspirin 150 mg OD
  6. T. Atorvastatin 40 mg ON
  7. S/C Actrapid (regular insulin) 6U PRN if DXT >12 mmol/L
  8. IV Frusemide (Lasix) 20 mg STAT then BD (KIV off cardiac monitor)
  9. Syrup Lansoprazole 30 mg BD
  10. IV Pantoprazole OD (commenced 0800H)
  11. S/C Actrapid 10U STAT (given 0225H)
  12. Wean oxygen - target NPO2; titrate to SpO2

01/06/2026 - Day 2

Subjective: No reported change. Remains on high flow mask.
Objective:
  • GCS: E3V1M6
  • BP: 116/65 mmHg | PR: 115 bpm | T: 37.0°C | SpO2: 97% on HFM
  • DXT: 12 mmol/L
  • Lungs: Bibasal crepitations (persisting)
  • Not tachypnoeic
Assessment: Stable respiratory status. Persistent bibasal crepitations - aspiration pneumonia ongoing. GCS unchanged.
Plan:
  1. Continue RT feeding 100 cc/3H
  2. Continue IV Augmentin
  3. Trace blood and sputum cultures
  4. DXT monitoring QID
  5. S/C Actrapid 6U PRN if DXT >12 mmol/L
  6. Strict input/output chart
  7. Continue IV Frusemide
  8. Wean to nasal prong O2 (NPO2) if SpO2 >95%
  9. CT Brain if GCS drops
  10. Inpatient ECHO (planned)
  11. CT Angiography (planned)

02/06/2026 - Day 3 (AM Review, 0910H)

Subjective: No verbal response. Left-sided weakness persisting.
Objective:
  • GCS: E4V1M6
  • Left-sided power: 0/5
  • Lungs: Clear
  • CXR: Pneumonia patches
  • ECG: Sinus rhythm, no atrial fibrillation
Assessment: GCS marginally improved (eye opening). Left-sided power remains absent. Pneumonic changes on CXR consistent with aspiration pneumonia.
Plan:
  1. Repeat CT Brain
  2. Trial off HFM/HPO2
  3. S/C Insulatard 10U STAT then BD
  4. Advance RT feeding: 150 cc x 3H → 200 cc x 3 → 250 cc x 2
  5. Continue IV Augmentin
  6. Start T. Metformin 500 mg BD STAT

02/06/2026 - Day 3 (PM Review, 1635H)

Subjective: Repeat CT Brain result reviewed.
Objective:
  • CT Brain: Small punctate haemorrhage with mass effect noted
Assessment: Haemorrhagic transformation of right MCA infarct with mass effect - significant development requiring urgent neurosurgical input and family counselling.
Counselling: Family counselled regarding potential for cardiorespiratory deterioration requiring intubation. Three possible outcomes discussed:
  1. Best outcome - clinical improvement
  2. Worsening neurological condition
  3. Prolonged ventilation requiring tracheostomy
Family also counselled on risk of cardiac arrest and CPR indication. Family remains indecisive - awaiting input from other family members.
Plan:
  1. IV Mannitol 200 mg STAT, then 100 mg TDS
  2. Withhold (W/H) Aspirin

02/06/2026 - Day 3 (Night Review, 2045H)

Subjective: Patient desaturated from NPO2 - SpO2 dropped to 88-89%; escalated back to HFMO2.
Objective (on HFMO2):
  • GCS: E4V1M5
  • Pupils: Reactive bilaterally
  • BP: 120/76 mmHg | PR: 146 bpm | T: 37.0°C | SpO2: 98%
  • DXT: 17 mmol/L (repeated result partially illegible ~23.1)
  • Ketones: 1.6 mmol/L
  • Lungs: Transmitted sounds
Assessment: Massive right MCA infarct with haemorrhagic transformation. Worsening mass effect. Tachycardia with escalating oxygen requirement. Likely raised intracranial pressure (ICP). Hyperglycaemia with mild ketonaemia.
Plan:
  1. Urgent Neurosurgical referral - massive cerebral infarct with haemorrhagic transformation (KIV right decompressive craniectomy)
  2. Await family decision regarding surgical intervention
  3. Withhold RT feeding and NBM (nil by mouth)
  4. Withhold Metformin and S/C insulin sliding scale
  5. Start insulin sliding scale 6 (IV/S/C)
  6. IV fluid: 30% NS over 24H
  7. IV fluid: 10% NS over 4H
  8. DXT monitoring 4-hourly
  9. Insert new branula

02/06/2026 - Day 3 (Late Night, 2330H)

Subjective: Family discussion completed regarding right decompressive craniectomy.
Family Decision: Family declines surgery, CPR, and intubation. Wishes for best medical therapy only.
Plan:
  1. Best Medical Therapy - conservative management
  2. Neurosurgical input (for medical advice only)
  3. Continue HFMO2; maintain SpO2 >95%
  4. Continue IV fluids
  5. Continue NBM with DXT monitoring and insulin sliding scale
  6. KIV Morphine SC if patient becomes restless or tachypnoeic (comfort care)

03/06/2026 - Day 4 (0920H)

Subjective: Patient desaturated on HFMO2 the previous day. Family input noted - conservative management agreed upon.
Objective:
  • GCS: E(not documented)V1M(not documented) - pupils equal but non-reactive, 2 mm bilaterally
  • BP: 121/77 mmHg | PR: 127 bpm | T: 37.0°C | SpO2: 99%
  • DXT: 6.7 mmol/L
  • Lungs: Clear anteriorly
Assessment: Fixed, equal, dilated pupils (2 mm, non-reactive) - indicating significant brainstem compromise or raised ICP with herniation. Haemodynamically borderline stable. Conservative (comfort-focused) management in keeping with family's wishes.
Plan:
  1. S/C Insulatard 10U STAT then BD
  2. Off insulin sliding scale
  3. Resume RT feeding 200 cc/3H
  4. IV Mannitol 100 mg TDS x 1 day then stop
  5. Off IV drip
  6. Off cardiac monitor
  7. For any desaturation: NOT for inotropes, intubation, or CPR (DNAR documented)
  8. Inpatient ECHO (as planned - TRO LV thrombus)
  9. Restart Aspirin

04/06/2026 - Day 5 (0920H)

Subjective: Currently afebrile. No desaturation on HFMO2. Tolerating RT feeding.
Objective:
  • GCS: E3V1M5 (moving right side of body)
  • BP: 133/85 mmHg | PR: not documented | T: 37.0°C | SpO2: 100% on HFMO2
  • DXT: 11.8 mmol/L
  • Lungs: Not documented this entry
Active Issues:
  1. Right MCA infarct with midline shift/mass effect - conservative management
  2. Aspiration pneumonia
  3. Uncontrolled DM
  4. AKI / ARI (query - to monitor)
Counselling: Caregiver counselled regarding high likelihood of vegetative state given massive stroke with mass effect. Family expressed interest in transferring to Aurelius Hospital - explained that patient is on Day 5 post-stroke and management approach will remain the same. Neurosurgical input at Aurelius also discussed - family to contact Aurelius Hospital directly.
Plan:
  1. Trial VMO2 60% (step-down from HFMO2)
  2. Increase S/C Insulatard to 14U BD
  3. Increase RT feeding to 250 cc/3H
  4. DXT monitoring QID
  5. Await family decision on transfer to Aurelius Hospital
  6. Inpatient ECHO (TRO LV thrombus) - pending
  7. Continue IV Augmentin (complete 1-week course)
  8. Off IV Mannitol (course completed)
Note prepared by: (Attending Physician) Date of note: 08/06/2026
These notes are formatted for clinical documentation purposes. Let me know if you need any section adjusted, expanded, or if you'd like a discharge summary or referral letter version instead.

My case is very complicated and as a pharmacy student I need to present why each drug is. Given I need to follow this flow [05/06, 17:28] anuu♥️: Flow of presentation: 1. Patient, age, gender 2. ⁠what is the chief complaint 3. ⁠what is the diagnosis 4. ⁠on day 1 admitted, wht problem then give what medication, indication for what, then is it appropriate to give the med for this problem, any more better option? (No pci then skip nxt day- same flow summary - until the last day) 5. ⁠next day, some symptoms resolve, dr stop certain medication due to …. Then some other problem arise and dr prescribe ….. the indication for the medication is for …… is it appropriate….. 6. ⁠overall no PCI in this case / u found some pci and need some clarification….. 7. ⁠thank you [05/06, 17:28] anuu♥️: Yes, but rather than solely mentioning if the medications are appropriate or not, it would be better to state indications. For eg, this pt was started on Tab pantoprazole 40mg BD for (indication) from (duration). Then if anything was found inappropriate/incorrect, it can be mentioned as a PCI & then explain accordingly [05/06, 17:28] anuu♥️: Your flow is correct. Just follow the CP2 sections.. and present according to the cp2 form.. explain all the terms clearly to me..eachand everything very detailly.. so that I'll be able to answer if my preectop ask anything about this case or out of box

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I have all the information I need. Now let me build the full CP2 pharmacy presentation:

CP2 PHARMACOTHERAPY REVIEW PRESENTATION

Hospital Sultanah Bahiyah (HSB) - Ward 31

SECTION A: DEMOGRAPHIC DATA

NameMd Rodzi bin Ismail
Age / Gender55 years / Male
RaceMalay
DOA30/05/2026
Chief ComplaintSudden onset left-sided body weakness, slurring of speech, and loss of consciousness at home at 1405H
AllergyNot documented (NKDA assumed - to clarify)
Vitals on Admission (KMC):
  • BP: 144/181 mmHg | HR: 87 bpm | DXT: 154 mg/dL (8.6 mmol/L) | SpO2: dropped to 80% RA on arrival at HSB ED
Past Medical History:
  • Type 2 Diabetes Mellitus (T2DM) - non-compliant to Jardiance (empagliflozin) and Diamicron (gliclazide)
  • Dyslipidaemia
  • Ischaemic Dilated Cardiomyopathy
Social History: Not documented

SECTION B: DIAGNOSIS

Primary Diagnosis: Acute right Middle Cerebral Artery (MCA) Infarct with left hemiparesis and aphasia - NIHSS 12
Secondary Diagnoses:
  1. Aspiration Pneumonia
  2. Decompensated Heart Failure with underlying Dilated Cardiomyopathy
  3. Uncontrolled Type 2 Diabetes Mellitus
  4. Right frontal encephalomalacia and gliosis (old lesion, noted on CT)
  5. Haemorrhagic transformation of MCA infarct (noted 02/06/2026)
  6. AKI/ARI (query, noted 04/06/2026)

EXPLAINING KEY TERMS (For Your Preceptor Questions)

MCA Infarct: The middle cerebral artery is the largest branch of the internal carotid artery. It supplies the lateral cerebral cortex including the motor and sensory cortex for the face, arm, and leg (contralateral side), as well as Broca's and Wernicke's speech areas. A right MCA infarct causes LEFT-sided motor deficits (hemiparesis) and can cause aphasia if dominant hemisphere is involved.
NIHSS 12: The National Institutes of Health Stroke Scale scores severity from 0-42. A score of 12 = moderate-severe stroke. This patient cannot receive IV thrombolysis (alteplase) as presentation was beyond the 4.5-hour window.
Encephalomalacia: Softening/necrosis of brain tissue from a previous infarct - this indicates a prior stroke event. Gliosis = reactive scarring around the old infarct. Pansinusitis = inflammation of all paranasal sinuses (incidental finding).
Haemorrhagic Transformation: A known complication of ischaemic stroke where blood leaks into the infarcted area due to reperfusion injury. Makes antiplatelet use potentially dangerous.
Decompensated Heart Failure with Dilated Cardiomyopathy: The heart muscle is weakened and dilated (from ischaemia), unable to pump adequately. "Decompensated" means the body can no longer compensate - presenting as pulmonary oedema (bibasal crepitations, low SpO2).

SECTION C: WARD MEDICATIONS - DAY BY DAY ANALYSIS

DAY 0 - 30/05/2026 (KMC + HSB ED)

1. T. Co-Plavix (Clopidogrel 75 mg + Aspirin 100 mg) - 1 tab STAT

Indication: Dual antiplatelet therapy (DAPT) for acute non-cardioembolic ischaemic stroke (right MCA infarct).
Mechanism:
  • Aspirin: Irreversibly inhibits COX-1 enzyme, preventing thromboxane A2 synthesis, which inhibits platelet aggregation.
  • Clopidogrel: A P2Y12 receptor antagonist that irreversibly blocks ADP-mediated platelet activation.
  • Together, they block two separate pathways of platelet aggregation, giving stronger anti-thrombotic protection.
Is it Appropriate? Yes - DAPT is the standard of care for acute non-cardioembolic ischaemic stroke. The CHANCE and POINT trials showed that aspirin + clopidogrel started within 24 hours of a minor-to-moderate ischaemic stroke significantly reduces recurrent stroke risk for 21 days compared to aspirin alone.
Concerns/PCI to note for later:
  • This patient has an NIHSS of 12 - technically considered moderate-severe stroke. DAPT is strongly indicated for minor stroke (NIHSS <3). For moderate-severe strokes, aspirin alone is sometimes preferred to avoid haemorrhagic risk. This is worth flagging as a potential PCI.
  • IMPORTANT: On 02/06/2026, CT Brain revealed haemorrhagic transformation. At this point, aspirin was withheld correctly by the doctor. This is appropriate because antiplatelet agents increase bleeding risk in the setting of intracerebral haemorrhage.

2. T. Lipitor (Atorvastatin) 40 mg STAT

Indication: High-intensity statin therapy for acute ischaemic stroke and background dyslipidaemia.
Mechanism: Atorvastatin inhibits HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis. This reduces LDL cholesterol. In acute stroke, statins also exert pleiotropic (non-lipid-lowering) effects: stabilising atherosclerotic plaques, reducing inflammation, and improving endothelial function (neuroprotection).
Is it Appropriate? Yes. AHA/ASA guidelines recommend high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) for all patients with ischaemic stroke due to atherosclerosis. This patient also has background dyslipidaemia. Atorvastatin 40 mg is appropriate. 80 mg could also have been used - this is a minor consideration.

DAY 1 - 31/05/2026 (Ward Admission)

New problems identified: GCS drop (E3V1M6), aspiration pneumonia, decompensated heart failure, hyperglycaemia, no gag reflex (aspiration risk), NIHSS 12.

3. IV Augmentin (Co-Amoxiclav - Amoxicillin 1.2g + Clavulanic Acid) IV, BD

Indication: Community-acquired aspiration pneumonia in a patient with impaired swallowing (absent gag reflex, post-stroke dysphagia).
Mechanism: Amoxicillin is a broad-spectrum beta-lactam antibiotic that inhibits bacterial cell wall synthesis. Clavulanic acid is a beta-lactamase inhibitor that protects amoxicillin from degradation by resistant organisms. Together, they cover gram-positive, gram-negative, and anaerobic organisms - which are the usual organisms in aspiration pneumonia (oral flora: Streptococcus, Bacteroides, Fusobacterium).
Is it Appropriate? Yes. Ampicillin-sulbactam (IV Augmentin = co-amoxiclav) is one of the first-line recommended agents for community-acquired aspiration pneumonia per Tintinalli's Emergency Medicine guidelines. It covers the key oral anaerobes. IV route is appropriate as the patient is NBM (nil by mouth) with no gag reflex.
Duration planned: 1 week (1/52) - appropriate for aspiration pneumonia.

4. T. Aspirin 150 mg OD (continued from Co-Plavix, now as monotherapy)

Indication: Secondary stroke prevention - antiplatelet therapy for acute ischaemic stroke.
Mechanism: Same as above. As monotherapy on Day 1, this continues antiplatelet coverage.
Note: Co-Plavix (DAPT) was given as a STAT dose at KMC. The continuation here with aspirin alone - without clopidogrel continued - may be a documentation gap or intentional clinical decision. Ideally, clopidogrel 75 mg OD should have been continued alongside aspirin for 21 days. This is a PCI - incomplete DAPT continuation.

5. T. Atorvastatin 40 mg ON (continued)

Indication: Same as above - secondary stroke prevention and dyslipidaemia management. ON = night-time dosing, which is appropriate as cholesterol synthesis peaks at night.

6. IV Pantoprazole 40 mg OD (started 31/5 at 0800H)

Indication: Stress ulcer prophylaxis in a critically ill stroke patient.
Mechanism: Pantoprazole is a proton pump inhibitor (PPI). It irreversibly binds to the H+/K+ ATPase enzyme in gastric parietal cells, blocking acid secretion. This protects the gastric mucosa from stress-induced ulceration, which is common in ICU/critically ill patients.
Why relevant here?
  • Critically ill patients (GCS-impaired, ventilator support, NBM) are at high risk of stress-related mucosal disease
  • Patient is also on antiplatelet therapy (aspirin), which irritates the gastric mucosa
  • Patient is nil by mouth (NPO) - unable to take oral feeds
Is it Appropriate? Yes. PPI use for stress ulcer prophylaxis in critically ill neurological patients is well-established. However, on Day 1, IV pantoprazole was prescribed AND syrup lansoprazole 30 mg BD was also added. This is a PCI - duplicate PPI therapy (pantoprazole + lansoprazole prescribed simultaneously).

7. Syrup Lansoprazole 30 mg BD

Indication: Same - stress ulcer prophylaxis / gastroprotection with aspirin use.
PCI: Duplicate PPI therapy - Pantoprazole IV OD + Lansoprazole 30 mg BD were both prescribed on the same day for the same indication. This is therapeutically duplicative. Recommendation: Continue only ONE PPI. Given patient will be on RT feeding, Syrup Lansoprazole via RT is appropriate and the IV pantoprazole could be stopped once enteral access is established.

8. S/C Actrapid (Regular Insulin) 10U STAT (given 0225H)

Indication: Acute management of hyperglycaemia (DXT >12 mmol/L in a stroke patient).
Mechanism: Regular insulin (Actrapid) is short-acting insulin that directly stimulates glucose uptake into cells via GLUT4 receptors, lowering blood glucose rapidly.
Why important in stroke? Hyperglycaemia worsens ischaemic stroke outcomes. High glucose promotes cerebral oedema, increases infarct volume, and worsens penumbra damage. Target glucose in acute stroke is generally 6-10 mmol/L.
Is it Appropriate? Yes - STAT correction of hyperglycaemia in acute stroke is appropriate.

9. S/C Actrapid 6U PRN if DXT >12 mmol/L

Indication: Sliding scale insulin for glycaemic control post-stroke.
Is it Appropriate? Acceptable short-term sliding scale. However, a basal insulin (like insulatard) would be more physiological for sustained control rather than reactive PRN dosing alone. The team later added basal insulin (Insulatard) on Day 3 - which is appropriate.

10. IV Frusemide (Lasix) 20 mg STAT then BD

Indication: Decompensated heart failure - fluid overload management.
Mechanism: Frusemide is a loop diuretic. It blocks the Na+/K+/2Cl- co-transporter in the thick ascending limb of the Loop of Henle, causing rapid diuresis. This reduces preload and pulmonary oedema.
Why needed? This patient has underlying ischaemic dilated cardiomyopathy. The bibasal crepitations, low SpO2, and tachycardia indicate acute decompensated heart failure with pulmonary oedema. Diuresis reduces the fluid overload.
Is it Appropriate? Yes. IV loop diuretics are the first-line treatment for acute decompensated heart failure (ADHF). IV route preferred over oral in the acute setting for faster onset. 20 mg BD is a reasonable starting dose.

DAY 2 - 01/06/2026

Status: GCS E3V1M6, bibasal creps persisting, SpO2 97% on HFM, PR 115, DXT 12. Stable but not improving significantly.
Changes: RT feeding commenced (100 cc/3H), cultures traced, I/O chart, continue antibiotics, continue IV Lasix, wean oxygen.
No new medications added this day. Plan continues from Day 1. Cultures pending.

DAY 3 MORNING - 02/06/2026 (0910H)

Status: GCS improved slightly to E4V1M6. Left power 0/5. Lungs clearing. CXR shows pneumonia patches. ECG sinus rhythm, no AF.

11. S/C Insulatard (Isophane/NPH Insulin) 10U STAT then BD

Indication: Basal insulin therapy for sustained glycaemic control in T2DM patient with acute stroke and hyperglycaemia. Replaces the ad hoc sliding scale as more consistent coverage.
Mechanism: Insulatard is intermediate-acting insulin (NPH - Neutral Protamine Hagedorn). It provides a steady baseline of insulin over 12-18 hours, preventing glucose excursions between meals/RT feeds.
Is it Appropriate? Yes - transitioning to a basal insulin is appropriate once the patient is more stable and receiving RT feeds. 10U BD is a reasonable starting dose.

12. T. Metformin 500 mg BD STAT and BD

Indication: Type 2 Diabetes Mellitus - blood glucose control.
Mechanism: Metformin is a biguanide. It works primarily by inhibiting hepatic gluconeogenesis (reduces glucose production by the liver) and improving peripheral insulin sensitivity. It does not stimulate insulin secretion, so hypoglycaemia risk is low.
Is this Appropriate? --- MAJOR PCI
NO. Metformin is CONTRAINDICATED here for multiple reasons:
  1. Decompensated Heart Failure: This patient has ischaemic dilated cardiomyopathy with acute decompensated heart failure. Metformin is contraindicated in acute/unstable heart failure because reduced cardiac output causes tissue hypoperfusion and hypoxia, which impairs lactate clearance. Metformin inhibits mitochondrial Complex I, reducing lactate clearance further, and risks lactic acidosis (a life-threatening complication).
  2. Acute Stroke / Acute Illness: In any acute illness with haemodynamic instability, metformin should be withheld. This patient had a massive MCA infarct with fluctuating GCS and cardiovascular compromise.
  3. Query AKI (noted Day 5 - 04/06): Metformin is renally excreted. Even suspected AKI is a contraindication as drug accumulation leads to lactic acidosis.
  4. NPO / RT feeding only: The patient is not eating, making glucose regulation unpredictable with metformin.
Recommendation: Metformin should NOT have been started on Day 3. Glycaemic control should rely on Insulatard BD + Actrapid sliding scale. The doctor did subsequently withhold metformin on 02/06/2026 evening (2045H) - which was the correct action - but it should not have been initiated in the first place.
Note: Metformin was indeed stopped the same evening when the patient deteriorated. This confirms it was clinically inappropriate.

DAY 3 AFTERNOON - 02/06/2026 (1635H)

New finding: Repeat CT Brain shows haemorrhagic transformation with mass effect.

13. IV Mannitol 200 mg STAT, then 100 mg TDS

Indication: Raised intracranial pressure (ICP) due to cerebral oedema and haemorrhagic transformation with mass effect.
Mechanism: Mannitol is an osmotic diuretic. It creates an osmotic gradient that draws fluid from the brain parenchyma into the bloodstream, thereby reducing cerebral oedema and lowering ICP. It also reduces CSF production and improves microcirculation.
Is it Appropriate? Yes. IV Mannitol is a standard medical therapy for raised ICP and cerebral oedema in massive ischaemic stroke with haemorrhagic transformation. The dose given (200 mg STAT then 100 mg TDS) appears to be in mg rather than the more conventional g (e.g., 20% mannitol 200 mL STAT = approximately 40g). This may be a documentation shorthand - clarify with your preceptor whether this refers to the dose in grams or mL volume of 20% mannitol solution.
Important note: Mannitol is a temporary bridging measure. Definitive treatment for mass effect is decompressive craniectomy - which was offered but refused by family.

14. Withholding (W/H) Aspirin

Reason: Haemorrhagic transformation on CT Brain. Antiplatelet therapy significantly increases bleeding risk in intracerebral haemorrhage. This is appropriate and consistent with guidelines.

DAY 3 EVENING - 02/06/2026 (2045H)

Patient desaturated. PR 146. Ketones 1.6. Worsening condition.

15. Insulin Sliding Scale 6 (S/C)

Indication: Hyperglycaemia management (DXT 17 mmol/L, ketones 1.6) in the context of acute illness and withheld metformin/basal insulin.
Is it Appropriate? Yes - appropriate to revert to a reactive sliding scale temporarily during acute deterioration while adjusting other medications.

16. IV 30% NS / 24H + IV 10% NS / 4H

Indication: Maintenance IV fluids - NBM patient, held RT feeding during acute deterioration.
Note: The use of hypertonic or higher-percentage saline (30% NS) in the context of cerebral oedema is actually beneficial - hypertonic saline reduces cerebral oedema similarly to mannitol. However, careful monitoring of serum sodium is required to avoid hypernatraemia. This is also used as a volume expander in the setting of haemodynamic compromise.

DAY 4 - 03/06/2026 (0920H)

Family decision: Conservative management only. DNAR documented.
New finding: Pupils equal but non-reactive, 2mm - indicates severe brainstem compromise.

17. KIV Morphine SC (prescribed as PRN - comfort care)

Indication: Palliative/comfort care for agitation, air hunger, or tachypnoea in a dying patient where family has declined resuscitation, intubation, and aggressive management.
Mechanism: Morphine is a mu-opioid receptor agonist. It reduces the subjective sensation of dyspnoea (breathlessness), provides analgesia, and has a sedative effect, improving comfort in end-of-life care.
Is it Appropriate? Yes. When aggressive treatment is withdrawn and comfort-focused care initiated, low-dose morphine is ethically and medically appropriate to relieve distress. This is standard palliative care practice.

18. Resume Aspirin (03/06/2026)

Indication: Secondary stroke prevention restarted after transient hold for haemorrhagic transformation.
Is it Appropriate? --- PCI for discussion
This is debatable. The patient was found to have haemorrhagic transformation on 02/06. Standard practice is to wait at least 24-72 hours (some guidelines say 1-4 weeks depending on haemorrhage size) before restarting antiplatelets after haemorrhagic transformation. Restarting within 24 hours may be premature, especially with documented mass effect and non-reactive pupils suggesting severe ICP. This could be raised as a potential PCI - however, in the context of best medical therapy and comfort care focus, the clinical team may have weighed the risk-benefit differently.

DAY 5 - 04/06/2026 (0920H)

19. Increase Insulatard to 14U BD

Indication: Persistent hyperglycaemia (DXT 11.8 mmol/L) on 10U BD. Dose uptitration for better glycaemic control.
Is it Appropriate? Yes - rational dose escalation based on DXT monitoring. Target DXT in stroke patients: 6-10 mmol/L.

20. Increase RT Feeding to 250 cc/3H

Indication: Nutritional support in an NBM patient with prolonged hospitalisation. Gradual advancement of enteral feeds is appropriate.
Note: RT (Ryle's Tube) feeding is the safest route for this patient as he has no gag reflex and is at very high risk for aspiration. PEG (percutaneous endoscopic gastrostomy) tube would be considered if the patient requires long-term enteral feeding (>4 weeks).

21. Trial VMO2 60% (Venturi Mask 60%)

Indication: Step-down oxygen therapy trial - attempting to wean from HFMO2 (High Flow Mask Oxygen) to lower-flow Venturi mask.

SECTION D: PHARMACEUTICAL CARE ISSUES (PCI) SUMMARY

#DatePCIRecommendation
130/05Co-Plavix STAT - DAPT not continued as clopidogrel 75 mg OD on subsequent daysRecommend adding Clopidogrel 75 mg OD for 21 days alongside aspirin per CHANCE/POINT trial evidence for minor-moderate stroke
231/05Duplicate PPI therapy - IV Pantoprazole OD + Syrup Lansoprazole 30 mg BD prescribed simultaneouslyStop one PPI. Keep Syrup Lansoprazole via RT. Discontinue IV Pantoprazole once enteral access established
302/06Metformin 500 mg BD started inappropriately in a patient with decompensated heart failure, acute stroke, and suspected AKIWithhold Metformin. Use Insulatard BD + sliding scale insulin for glycaemic control. Metformin was correctly withheld that same evening
403/06Aspirin restarted <24H after documented haemorrhagic transformation and mass effectDelay aspirin restart by at least 72 hours or until haemorrhage is confirmed stable on repeat imaging
5OverallNo thrombolysis (IV Alteplase) - was this considered?Patient arrived at HSB ED at 1900H. Symptom onset 1405H = ~5.5 hours. Beyond 4.5-hour window for IV thrombolysis. Therefore, thrombolysis is NOT indicated here. Correct.
6OverallNo mechanical thrombectomy (EVT) - was this considered?Large vessel occlusion (MCA infarct) with NIHSS 12. EVT could have been considered if within 6-24 hour window and accessible vessel. However, not available at HSB (require tertiary neurosurgical centre). Family also declined invasive procedures. No PCI - appropriate in context.
7OverallNon-compliance to Jardiance (Empagliflozin) and Diamicron (Gliclazide)Patient's pre-existing DM medications were not restarted during admission due to NPO status and acute illness - this is appropriate. Post-discharge, reassess and potentially restart with education on compliance.

SECTION: OVERALL NO PCI / PCI FOUND

PCIs Found in This Case:
  1. Incomplete DAPT - Co-Plavix given as STAT, clopidogrel not explicitly continued as a separate daily dose
  2. Duplicate PPI therapy - pantoprazole IV + lansoprazole syrup started simultaneously
  3. Inappropriate metformin initiation - contraindicated in decompensated heart failure, acute stroke, and suspected AKI (subsequently withheld correctly)
  4. Early aspirin restart - restarted within 24 hours of confirmed haemorrhagic transformation
No PCI (appropriate decisions):
  • No IV thrombolysis (beyond 4.5H window)
  • No mechanical thrombectomy (facility limitation and patient/family refusal of invasive procedures)
  • Withholding aspirin on haemorrhagic transformation - correct
  • IV Augmentin for aspiration pneumonia - correct
  • IV Lasix for decompensated heart failure - correct
  • IV Mannitol for raised ICP - correct
  • DNAR/comfort care plan documented with family - ethically appropriate

GLOSSARY OF TERMS (For Your Preceptor Questions)

TermExplanation
NIHSSNational Institutes of Health Stroke Scale - scores stroke severity 0-42. This patient scored 12 (moderate-severe)
GCSGlasgow Coma Scale - assesses consciousness (Eye, Verbal, Motor). E3V1M6 = eyes open to voice, no verbal response, obeys commands
DAPTDual Antiplatelet Therapy - aspirin + clopidogrel together
HFM / HFMO2High Flow Mask / High Flow oxygen delivery system
NPO2Nasal Prong Oxygen - lower-flow oxygen delivery
FMO2Face Mask Oxygen
RT / RTFRyle's Tube / Ryle's Tube Feeding - nasogastric tube for enteral nutrition
DXTDextrostix - bedside blood glucose monitoring
QIDFour times daily
ODOnce daily
BDTwice daily
PRNAs needed
STATImmediately
KIVKeep in view - ordered but only used if condition warrants
W/HWithhold
DNARDo Not Attempt Resuscitation
PCIPharmaceutical Care Issue - a drug-related problem identified by the pharmacist
Bibasal crepsCrackles heard at the base of both lungs - sign of pulmonary oedema or pneumonia
Haemorrhagic transformationBleeding into an ischaemic infarct area - complication of stroke
Mass effectBrain tissue being pushed/compressed by a growing lesion - indicates raised ICP
Decompressive craniectomySurgical removal of part of skull to relieve brain pressure - offered but refused by family
LV thrombusBlood clot forming in the left ventricle - a risk in dilated cardiomyopathy that can embolise and cause stroke (ECHO ordered to exclude this)
ECHOEchocardiogram - cardiac ultrasound
TROTo rule out
PenumbraReversibly ischaemic brain tissue surrounding the infarct core - target of stroke treatment
Lactic acidosisLife-threatening complication of metformin in hypoxic/hypoperfused states
This presentation follows the CP2 form flow completely. You should be able to walk through it day by day, explain every drug's indication, mechanism, appropriateness, and flag each PCI with a recommendation. Let me know if you want me to expand on any specific drug, simplify any section, or format this as a printable Word/PDF document.
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