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SOAP

Noufal.A
• SOAP was originally designed by
Dr. Lawrence L. Weed for medical doctors
• Method of written documentation based on the
"pharmacists view on drug therapy”
• PWDT (pharmacist's workup of drug therapy)
• PMDRP (Pharmacist's Management of Drug--
Related Problems)
• PCP (pharmacist's care plan)
• Subjective: This is the story that is told in the
patient's own words
• Objective: Results of all examinations
• Assessment: Make a comment on what is going
on with the patient. Record here your differential
diagnosis, working diagnosis and steps you might
take to confirm or deny each item
• Planning: explanation of treatment into what was
done today and what will done at the next or
future visits
CASE STUDY
52-year-old, 80 kg, male who comes to the
clinic with continued complaints of shortness
of breath and increased sputum production.
He reports that a rash began yesterday.
He also complains of feeling depressed,
lacking energy ,waking up early in the
morning and not being able to go back to
sleep,a decreased appetite,a general lack of
interest in everything, including his job and
his family for the last 6 weeks.
 Although he has several medical problems, he has
been doing well prior to this episode
CHIEF COMPLAINT

• 52-year-old man who comes to the clinic


today with complaints of
– shortness of breath (SOB)
– increased sputum production.
HISTORY OF PRESENT ILLNESS
• He reports that a rash began yesterday.
He also complains of feeling depressed,
Lacking energy
Waking up early in the morning
Not being able to go back to sleep,
A decreased appetite,
A general lack of interest in everything, including
his job and his family for the last 6 weeks.
Although he has several medical problems, he has
been doing well prior to this episode
PAST MEDICAL HISTORY
♠ Chronic bronchitis secondary to smoking.
Increasing SOB over last two years.
♠ Patient injured his right leg in a fall seven
months ago.
۩Deep vein thrombosis in the calf developed a week
later.
SOCIAL HISTORY
⇒He has a stable and happy marriage; he has
two sons.
⇒Continues to smoke 1 pack per day;
ALLERGIES
None known
MEDICATION HISTORY
Theodur 600 mg bid for 2 years
Terbutaline inhaler 4 puffs qid and PM
for 2 years
Vibramycin 100 mg qd x 10 days
Warfarin 3 mg qd, started 7 months ago
Acetaminophen prn headache
PHYSICAL EXAMINATION
 GEN :-Middle aged man, in severe distress
 VS :-BP- 120/80 mm of hg, HR- 100 bpm,
T -37.60C, RR- 32, Wt -80 kg, Ht- 5’7”
 HEENT :- Normal
 COR :-Normal S1 and S2; no S3, S4 or murmurs
 CHEST :- Numerous rales, rhonchi, and wheezes
 ABD :-No organomegaly
 GU :-WNL
 RECT :-WN
 EXT :-NL DTRs, maculopapular rash on trunk & thighs
 NEURO :-Oriented x 3, WNL
RESULTS OF LABORATORY TESTS
• Na -140 (135 -145 mEq/L) •Ca -8.8 (8.5 to 10.2 mg/dL)
• BUN -37 (7 - 20 mg/dl )
• Hct -55 (40.7 - 50.3%)
• Cr -1.2 (0.8 to 1.4 mg/dl)
• Alb -4 (3.4 - 5.4 g/dL) • P04 -2.6(2.5 – 4.5mg/dl)
• K -4.0 (3.5-5.3 mEq/L) • AST- 40 (5-40U/L)
• Hgb -17.5 (14-17.5g/dl) • ALT -35 (5-40U/L)
• TBili -0.8(0.3 to 1.9 mg/dL) •PT -25 (12-15 sec)
• Cl -101 (96 - 106 mEq/L) •INR=3 (0.8-1.2)
• WBC 8.1(3.8 - 10.8 thous/mcl )
• Glu -95 (70-120 mg/dL)
• Uric acid -7.47.4(3.0 -7.0
mg/dL)
• WBC differential:- N 48, L 30, M 5, E18
• ABGs:- pH 7.37, PO2 55, PCO2 49
• PFTs:- pre-bronchodilator FEV1 = 2000 mL
(50% of FVC), post-bronchodilator FEV1 =
2600 mL (65% of FVC)
• Gram stain of sputum sample was unsuitable
due to numerous squamous epithelial cells
• Urinalysis:- WNL
• Chest x-ray:- Clear, no signs of pneumonia
PROBLEM LIST
1.Chronic bronchitis in an acute
exacerbation
2. Drug allergy
3. Depression
4. Deep Vein Thrombosis
PROBLEM 1
CHRONIC BRONCHITIS
EXACERBATION
PROBLEM 1
CHRONIC BRONCHITIS EXACERBATION
• S:- He complains of SOB and increased
sputum production.
• O:-He has a decreased FEV1, rales, rhonchi,
wheezes, an increased respiratory rate, pulse,
Hct and Hgb, and arterial blood gases that
show an increased PCO2 and a decreased
oxygen. He has smoking history.
• A:-
• He has a symptomatic exacerbation of his chronic
bronchitis that requires treatment.
 Smoking is the most likely etiology of the chronic
bronchitis, while a viral upper respiratory tract infection is
probably the cause of the acute exacerbation since he shows
no signs of systemic bacterial infection.
• He has a normal WBC, he is afebrile, and his chest
x-ray is clear. The use of antibiotics in this situation is
controversial, although recent evidence suggests a
benefit.
• Pre-bronchodilator and post bronchodilator FEV1
show reversible airway obstruction. The theophylline
level is within the therapeutic range and there is no
need to increase the dose.
• P:-
Give methylprednisolone 40-125 mg iv stat and
continue q6h for 72 hours.
Give aerosolized Terbutaline 4 puffs stat and 1
puff q 5 minutes until relief or appearance of side
effects.
Continue oral theophylline.
Begin oxygen 2 liters/minute via nasal prongs.
Begin ampicillin 500mg po qid.
Contd ….
Contd ….

• Monitor SOB, sputum production, FEV1, ABGs,


chest auscultation, theophylline level, nausea,
vomiting, pulse, blood glucose, serum potassium,
blood pressure, and tremor.
• The goal is to decrease morbidity and mortality
associated with chronic bronchitis.
• Assess his ability to use his inhaler correctly and
correct any problems. Provide a spacer if necessary.
• Explain the likely side effects of theophylline,
steroids, and ampicillin. He should discontinue
smoking; refer him to a smoking cessation clinic.
• PROBLEM 2
DRUG ALLERGY
PROBLEM 2
DRUG ALLERGY
• S:- Complains of a rash that began yesterday, but does not
complain of itching.
• O:- He has maculopapular rash on trunk and thighs, his
eosinophiles are 18
• A:-He has developed a rash due to the doxycycline started 9
days ago. The usual drug rash is maculopapular and
commonly occurs after 7-10 days of therapy. Avoid
antihistamines unless he is itching, because they are
sedating and have anticholinergic effects.
• P: Discontinue Vibramycin. Calamine lotion for a soothing
effect may be needed. Label “he is allergic to doxycycline”.
Monitor for resolution of the rash. Educate patient that he
has an allergy to doxycycline and possibly other
tetracyclines.
• PROBLEM 3
DEPRESSION
PROBLEM 3
DEPRESSION
• S: He complains of feeling depressed, lacking energy,
waking up early in the morning and not being able to go
back to sleep, a decreased appetite, and a general lack of
interest in everything, including his job and his family for
the last 6 weeks.
• O: None.
• A: He has had his current complaints for more than a
month.
 While he does not appear to be suicidal at this point, he needs
treatment.
 Fluoxetine is as effective, has less side effects, and, when all
costs are taken into account, is no more expensive to use than
older tricyclic antidepressants such as imipramine and
desipramine.
• P:
• Begin fluoxetine 20 mg qd in AM or at noon. Continue therapy
for 6 months.
• Monitor changes in appetite, sleep pattern, interest in life,
mood, quality of life, and suicidal thoughts.
• Physiologic signs and symptoms should improve in 1 week,
while mood will take 2-4 weeks to respond.
• Also monitor for headaches, anxiety, insomnia, nausea,
somnolence, dizziness or anticholinergic side effects.
• Advise patient to take fluoxetine in the morning or at noon to
help prevent insomnia.
• Antacids may help with nausea.
• This drug may cause drowsiness or dizziness, so caution is
advised when driving or operating machinery.
• It will take several weeks for this drug to work or side effects
to develop.
• PROBLEM 4
DEEP VEIN THROMBOSIS
PROBLEM 4
DEEP VEIN THROMBOSIS
• S: No complaints
• O: The measurements of INR have shown wide swings
over the last seven months. Presently the INR has
stabilized around 3.0 for the last two months.
• A: Since the patient had only one occurrence of deep
vein thrombosis, warfarin therapy is usually
discontinued after six months of prophylactic treatment.
• P: Discontinue warfarin