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Similar to Migraine case Presentation SOAP format for PharmD students
Migraine case Presentation SOAP format for PharmD students
- 1. Abel C. Mathew 4thyear PharmD Al Shifa College of Pharmacy 1 A CASE ON CLASSIC MIGRAINE
- 2. • NAME :XYZ • AGE : 60 years • SEX : Female • MRD NO : xxxxx • DOA :14/02/2018 • DOD :16/02/2018 • Dept: General Medicine I 2 PATIENT DEMOGRAPHIC DETAILS
- 3. REASON FOR ADMISSION Irritability,headache with flickering lights and visual disturbances, and generalised weakness since one day. History of abnormal sensation of abdominal and limb muscles. Patient was also suffering from sleepiness and giddiness 3
- 4. MEDICAL HISTORY Type 2DM , Hypertension, diabetic neuropathy, Age related functional dyspepsia MEDICATION HISTORY •Inj. Human Mixtard •Levosulpiride 25mg FAMILY HISTORY No relevant family history SOCIAL HISTORY Not relevant 4
- 5. ON EXAMINATION • Conscious •Oriented • Afebrile • PR -92/mt, B.P- 160/100 mmHg, RR- 16 /mt , • P/A- soft • Chest – NVBS • CVS- S1S2+ 5
- 6. PROVISIONAL DIAGNOSIS Classic Migraine,Type 2 DM, Hypertension, diabetic neuropathy, Akathisia- Levosulpiride induced 6
- 7. LAB ADVICES • BRE •LFT • RBS • URINE ACETONE 7
- 8. TEST VALUE NORMAL RBC4.44million/mm3 150-450 WBC 11.64x1000c/cu 4-11 NEUTROPHILS 65% 45-75 LYMPHOCYTES 28% 20-45 BASOPHILS 00% 0-1 EOSINOPHILS 03% 0-6 MONOCYTES 04% 0-7 PLATELETS 330 X 1000 c/cu 150-450 MCV 66.3FL 66-96 MCH 30.1pg 27-32 MCHC 34.1% 32-36 8 LAB REPORTS
- 9. RDW 12.8% 11-16 PCT0.25% 0.13-0.35 PDW 44.2% 24-65 ESR 80mm/hr 0-20 ALBUMIN 4.4g/dl 3.5-5.5 GLOBULIN 3.3g/dl 2.3-3.5 TOTAL PROTEIN 7.7g/dl 6.4-8.3 AST 29.8 U/I 8-40 9
- 10. 10 ALT 28.2 U/I5-35 ALKALINE PHOSPHATASE 125U/I 30-130 BILIRUBIN TOTAL 0.45 mg/dl 0.29-1.2 DIRECT BILIRUBIN 0.23mg/dl 15-45 INDIRECT BILIRUBIN 0.22mg/dl 70-150 URINE ACETONE NEGATIVE SERUM SODIUM 138mEq/L 135-145 SERUM POTASSIUM 4.18mEq/L 3.5-5.5 RBS 173mg/dl 70-150
- 11. Classic Migraine, Type2 DM, Hypertension, diabetic neuropathy, Akathisia- Levosulpiride induced 11 FINAL DIAGNOSIS
- 12.
- 13. DRUG BRAND NAME GENERICNAME WITH DOSE, ROUTE, FREQUENCY Day1 Day 2 Day3 1. TAB.TELISTA Telmisartan 40 mg P/O BD + + 2. CAP.RENERVE PLUS Alpha lipoic acid 200 mg + Chromium 200 mcg + folic acid 1.5 mg + inositol 100 mg + mecobalamin 1500 MCG + + + 3. TAB.NAPROSYN Naproxen 500 mg P/O 1-0-1 + + 4. TAB.OXETOL Oxcarbazepine 150mg P/O TID + + + 5. TAB.PHENERGAN Promethazine 50 mg P/O HS + + 6.TAB.ACOTRUST Acotiamide 100mg P/O ½ -½ -½ + + 7. TAB.SEMSIVAL P Pregabalin (75mg)+ Nortryptyline(10 mg) P/O ½ HS + 8. GABAPENTIN OINTMENT 20g L/A Gabapentin apply to affected area + 9.INJ. HUMAN MIXTARD (30/70) Isophane insulin(70%) + Soluble insulin(30%) s/c BD + + + 1313
- 14. • 1.TAB.TELISTA 40mg (Telmisartan) 1-0-1 • 2.CAP. RENERVE PLUS( Folic acid+ mecobalamin+ chromium+Inositol+ Alpha lipoic acid) 1- 0-0 • 3.TAB PHENERGAN 50mg (Promethazine) 0 – 0-1 • 4.TAB.ACOTRUST (Acotiamide) ½ -½ -½ • 5.TAB VENTAB DXT 25mg (Desvenlafaxine) 0 - 0- ½ • 6.GABAPENTIN OINTMENT 20g L/A (Gabapentin) • 7.T.SIBELIUM 10 mg (Flunarizine) 0-0-1 • 8. SYP. MUCAINE GEL 2tsp (½ hour before food ) 14 4 DAYS
- 15. PROGRESS CHART 15 DAYS INVESTIGATIONS 14/02 15/02 16/02 Irritability,Headache and patient suffered from heart burn and Syp. Mucaine gel 2 tsp was given as stat. (PR 92b/min ; RR 16 b/min ; BP 100/80 ; Temp98.6º F) Pain was decreased and vitals were stable (PR 82 b/min ; RR 18 b/min ; BP140/90 ; Temp; 98.6º F) All vital signs were normal and symptomatically better( PR 76b/min ; RR 18 b/min ; BP 130/90; Temp 98.6ºF)
- 16. • Review after4 days with FBS, PPBS reports . 16
- 17. • Avoid migrainetriggers like stress, bright lights, some foods and medications, too much or too little sleep, and menstruation. • Keep well hydrated. • Maintain a regular schedule for eating and sleeping 17
- 18.
- 19. • A 64year old female patient having weight of 55 kg was admitted in the department of general medicine with complaints of Irritability, headache, and generalised weakness since one day. History of abnormal sensation of abdominal and limb muscles. Patient was also suffering from sleepiness and giddiness. 19
- 20. 20. Past history ofclassic migraine and age related gastric movement discomfort for which patient was on levosulpiride 1. Elevated WBC (11640 cells/ cu) 2. Restlessness of limbs was observed during examination 3. Elevated RBS (173 mg/dl)
- 21. Based on subjectiveand objective evidences the case was diagnosed Classic Migraine, Type 2 DM , Hypertension, diabetic neuropathy, Akathisia- Levosulpiride induced Etiology : • Genetic predisposition • Previous episodes of migraine headaches • Bright lights • Akathisia was propably levosulpiride induced 21
- 22. Assessment of currenttherapy- Rationality of each drug: • Flunarizine Lucking et al. (1988) compared flunarizine 10 mg daily with propranolol 40 mg 3 times a day over a 16-week period in 2 identically designed double-blind studies in Germany in adults with a history of migraine. The first study included 87 people and second study included 434 people. In the primary care study, the frequency of migraine attacks was reduced in 54.5% of people in the flunarizine group and 53.1% of people in the propranolol group after 4 months of treatment • Oxcarbazepine A study conducted by Muke Zou et.al 2013 randomised, placebo- controlled, double-blind trials with a total of 862 participants the review found evidence to support the effectiveness of oxcarbazepine in painful diabetic neuropathy, neuropathic pain from radiculopathy and mixed neuropathies of various causes. 22
- 23. • Desvenlafaxine In arandomised double blind controlled trial done by Boyer.P et.al (2015), which analysed 874 patients at the end of 6 month double blind treatment, better efficacy was found among the desvenlafaxine than placebo treated patients on all efficacy end points. • Nortryptyline & Gabapentin Chandra 2006 reported that 14/34 participants experienced our preferred outcome of at least 50% reduction in pain intensity (using 100 mm VAS) with nortriptyline, and 13/36 with gabapentin. Numbers were somewhat lower in both groups using a Likert scale. The study also reported a responder outcome of 'good or excellent', defined as participants with "no worse than mild pain and disability, tolerable side effects, who slept well and were satisfied with treatment". This was experienced by 16/36 participants with nortriptyline and 16/34 with gabapentin. • Naproxen Lawrencew Richer et. Al 2016 identified 27 randomized controlled trials (RCTs) of migraine symptom-relieving medications, in which 9158 children and adolescents were enrolled and 7630 (range of mean age between 8.2 and 14.7 years) received medication. Naproxen was more effective than placebo in producing pain freedom in two small studies involving children. In one small cross-over study in adolescents, naproxenwas not superior to placebo for pain freedom, but it was for headache relief (Evers 2006). 23
- 24. • Acotiamide MasahiroUeda, et. al 2016 Efficacy of acotiamide for improving symptoms in patients with functional dyspepsia was shown by several clinical trials. In a randomized, double-blind, placebo-controlled, parallel-group comparative Phase III trial conducted in Japan, 100 mg of acotiamide three times a day for 4 weeks was more effective than a placebo for improving symptoms, and quality of life. 24
- 25. • Patient respondedwell to the therapy , symptoms was reduced 25
- 26. The administration ofpromethazine with nortryptyline increases sedation. 26 Sl No Drug 1 Drug 2 Intensity of interaction Significant effects in Patient Whether if it is clinically seen 1 Promethazine Nortryptyline Minor Both drugs increases sedation No
- 27. • Patient wasfound to be compliant to the medications given. 27
- 28. • 1. Tricyclicantidepressants are the second line drugs used in the prophylactic management of migraine Tricyclic antidepressants are good second-line alternatives because of their adverse-effect profile and efficacy. • 2. Some anti-seizure drugs, such as valproate and topiramate seem to reduce the frequency of migraines. 28
- 29. Goals of therapy: •1. Reduce attack frequency and severity. • 2. Reduce disability • 3. Improve quality of life • 4. Prevent headache • 5. Avoid headache medication escalation • 6. Educate and enable patients to manage their disease 29
- 30. • 1. Symptomaticimprovement is seen • 2. Patient is stable at the time of discharge. 30
- 31. 1. NAPROXEN - Monitorfor signs/symptoms of gastrointestinal bleeding. -Monitor blood counts, renal, and hepatic function periodically for patients receiving long-term therapy. 2. TELMISARTAN Monitoring: Monitor serum electrolytes periodically. 3. PROMETHAZINE Excessive sedation -Respiratory rate, especially in paediatric patients -Localized injection site reactions 4. OXCARBAZEPINE -Monitor for serious dermatologic reactions, such as Stevens- Johnson syndrome and toxic epidermal necrolysis , Hyponatremia --- -Psychiatric: Emergence or worsening of depression, suicidal thoughts or behaviour, and/or any unusual changes in mood or behavior. 31
- 32. Drugs that cancause rebound headaches are: • • NSAIDs • • Codeine andprescription pain relievers • • Medicines that contain caffeine • • Birth control pills • • Triptans . 32
- 33. • Tricyclic antidepressantscan be used instead of SNRIs for better prophylactic management of migraine. No NSAIDs was given to patient for the acute migraine attack management 33
- 34. 34 A. On disease •A migraine is a primary headache disorder characterized by recurrent headaches that are moderate to severe. Typically, the headaches affect one half of the head, are pulsating in nature, and last from two to 72 hours. Associated symptoms may include nausea, vomiting, and sensitivity to light, sound, or smell. • Extrapyramidal symptoms are forms of abnormal body movements that are caused by a blockade of normal dopamine functions in the brain. occur most commonly as side-effects of antipsychotics
- 35. B. On diet Certainfoods can be triggers for migraines in susceptible people. These foods include: • red wines, • aged cheeses, • preservatives used in smoked meats (nitrates) • monosodium glutamate • artificial sweeteners • chocolate, and • Dairy products. 35
- 36. C. On lifestylemodifications • • Keep well hydrated since dehydrationhas been identified as a migraine trigger for some people • • Avoid certain foods that might trigger a migraine • • Maintain a regular schedule for eating and sleeping • • Exercise regularly 36
- 37. D. On drugs •• Ibuprofen • Stop this drug if you have symptoms of stomach bleeding such as black, bloody, or tarry stools, or coughing up blood or vomit that looks like coffee grounds. • • Telmisartan • Avoid drinking alcohol. It can lower your blood pressure. Do not use potassium supplements or salt substitutes while you are taking telmisartan • • Promethazine • Stop using this medication if you have twitching or uncontrollable movements of your eyes, lips, tongue, face, arms, or legs 37
- 38. 38 • Oxcarbazepine It reducesthe sodium in your body to dangerously low levels, which can cause a life-threatening electrolyte imbalance. Headache, weakness, loss of appetite, feeling unsteady • Flunarizine Swallow it as a whole. Do not chew, crush or break it. Tablet may be taken with or without food •Desvenlafaxine Swallow it as a whole. Do not chew, crush or break it.
- 39. Review after 4daysdays in General medicine department with FBS, PPBS results 39
- 40.