Case analysis in SOAP format

SOAP notes are a highly structured format for documenting the progress of a patient during treatment and is only one of many possible formats that could be used by a health professional. They are entered in the patients medical record by healthcare professionals to communicate information to other providers of care, to provide evidence of patient contact and to inform the Clinical Reasoning process.

SOAP is an acronym for:

Subjective - What the patient says about the problem / intervention.
Objective - The therapists objective observations and treatment interventions (e.g. ROM, Outcome Measures)
Assessment - The therapists analysis of the various components of the assessment.
Plan - How the treatment will be developed to the reach the goals or objectives.
Here i am presenting a meningitis case in the form of soap note.

1. CASE ANALYSIS PRESENTED BY ALIDA VINS VS FIFTH PHARM D

2. SUBJECTIVE Mrs. Denisha , a 27 year old female was admitted in the general ward with chief complaints of dizziness, headache, breathing difficulty and two episodes of seizure.

3. OBJECTIVE 1.Vital signs PR:102 b/min RR:22 b/min BP:190/110 mmHg T: 98.6 degree F

4. 2.Lab data Abnormal findings BLOOD BIOCHEMICAL ESTIMATIONS DATE PARAMETER OBSERVED VALUE INTERPRETATION 29/11/19 POTASSIUM 7.10mg/dl Chronic kidney Disease (CKD) 30/11/19 POTASSIUM 6.0mg/dl CKD CSF SUGAR 58.00mg/100ml Meningitis, Seizure. CSF PROTEIN 87.00mg/dl Meningitis, Seizures. 01/12/19 POTASSIUM 7.5mg/dl CKD

5. 2/12/19 UREA BLOOD 87.00 mg/dl CKD CREATININE SERUM 10.7 mg/dl CKD SODIUM 139 mg/dl CKD, HTN 3/12/19 SODIUM 139 mg/dl CKD, HTN CREATININE SERUM 8.30 mg/dl CKD b) Normal findings Other lab datas were found to be normal .

6. 4 . Other investigations a) Urine analysis Albumin: +++ Sugar: Present PUS cells: 2.5 HPF b)Microbiology Smear for acid fast bacteria from CSF specimen -Streptococcus Pneumonia 5.Past medical history a)Co morbidities: Hypertension (HTN) b)Social Habits: Not Known 6.Diagnosis Meningitis Chronic Kidney Disease (CKD)

7. 7) Present medication DRUG DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 DAY 8 INDICATION T.Amlong Antihypertensive T.Hasurge Vitamin supplement T.Pantocid Acid suppression T.Atorax Decrease brain activity T.Revlamer CKD INJ.Epotrust CKD INJ.Calcium gluconate CKD INJ.Dextrose Caloric supplement NEB.Asthalin Breathing difficulty

8. Potassium bind Sachet CKD INJ.Taxim Meningitis INJ.Valparin Chrono Seizure T.Atorva Prophylaxis to cholesterol T.Dolo Fever T.Epilex Chrono Seizure T.Levacetam Seizure INJ.Piptaz Prophylaxis to Bacterial infection INJ.CP Meningitis T.Sevalmer CKD

9. PROGRESS TEMP (degree F) PR(beats/min) RR(beats/min) BP (mmHg) FBS (mg/dl) I 0 ( ml ) DAY 1 98.6 102 22 190/110 --- --- DAY 2 100.2 102 24 150/90 48 2000/200 DAY 3 98 78 20 150/80 118 2000/200 DAY 4 98.6 100 20 110/80 132 2100/200 DAY 5 98.6 70 22 150/80 70 1200/600 DAY 6 98.6 94 20 160/100 158 1500/400 DAY 7 98.6 82 22 160/100 150 1500/600 DAY 8 98.6 78 22 180/100 --- 195/750

10. PRESCRIPTION ANALYSIS DRUG FREQUENCY CATEGORY INDICATION T.Amlong 5mg ( Amlodipine ) 1-0-1 P/O Antihypertensive agent Due to high blood pressure T.Hasurge 1-0-1 P/O Vitamin supplement Vitamin deficiency T.Pantocid 40mg ( Pantoprazole ) 1-0-0 P/O Proton pump inhibitor To suppress acidity in stomach T.Atorax 10mg ( Hydroxyzine ) 0-0-1P/O Anti histamine To decrease brain activity and relax T.Revlamer 400mg 1-1-1 P/O Phosphate binders Due to CKD INJ.Epotrust 2000IU ( Erythropoetin ) 3/7 Erythropoesis stimulating agents To prohibit anemia due to CKD INJ.Calcium gluconate 10ml Q8H IV Mineral supplement To treat high potassium level in blood INJ. 25%Dextrose 100ml 100 H.A Q8H IV Fluid Replenisher For Dizziness and Hypoglycemia NEB.Asthalin ( Salbutamol ) Q4H Beta 2 adrenergic receptor agonist To reduce Breathing difficulty.

11. Potassium bind sachet 15g 1-1-1 P/O Potassium binder Due to high potassium level. INJ.Taxim 1g ( Cefotaxim ) BD IV Cephalosporin Antibiotic To treat Meningitis INJ.Valparin Chrono 300mg ( Valproic acid) 1-0-0 IV Antiepileptic drug To treat episodes of seizures T.Atorva 10mg ( Atorvastatin ) 0-0-1 P/O HMG- CoA redcuctase inhibitor Prophylaxis to cholesterol T.Dolo 650mg (Acetaminophen) SOS P/O Antipyretic agent To treat fever T.Epilex Chrono 300mg ( Valporate ) 1-0-1 P/O Antiepileptic drug To treat Seizure T.Levacetam 500mg ( Levetiracetam ) 0-0-1 P/O Antiepileptic drug To treat Seizure INJ.Piptaz 4.5 g ( Piperacillin+Tazobactam ) BD Penicillin Antibiotic To treat m eningitis INJ.CP 20lakh (Benzyl penicillin) Q6H IV Penicillin Antibiotic To treat meningitis T.Sevalmer 400mg 1-1-1 P/O Phosphate binders Due to CKD

12. DRUG INTERACTION No severe Drug-Drug interactions were found.

13. ASSESMENT DIAGNOSIS Meningitis Chronic Kidney Disease on HD COMORBIDITIES Hypertension (HTN) ALLERGIES Nil

14. PLAN SL NO DRUG & DOSE REASON FOR CHANGE / ADDITION 1. T.Amlong 5mg 1-0-1 No change 2. T.Hasurge No change 3. T.Pantocid 40mg 1-0-1 P/O No change 4. T.Atorax 10mg 0-0-1 P/O No change 5. INJ.Revalmer 400mg 1-1-1 P/O No change 6. INJ.Epotrust 2000 IU 3/7 No change 7. INJ.Calcium gluconate 10ml Q8H IV No change 8. INJ.Dextrose 100ml 100HA No change 9. NEB Asthalin Q4H No change 10. Potassium bind sachet 15g 1-1-1 No change 11. INJ.Taxim 1g BD IV No change 12. INJ.Valparin Chrono 300mg 1-0-0 No change

15. 14. T.Dolo 650mg SOS P/O No change 15. T.Epilex Chrono 300mg 1-0-1 P/O No change 16. T.Levacetam 500mg 0-0-1 P/O No change 17. INJ.Piptaz 4.5 g BD No change 18. INJ.CP 20Lakh Q6H IV No change 13. T.Atorva 10mg 0-0-1 No proper indication 19. T.Sevalmer 400mg 1-1-1 Duplication

16. PATIENT COUNSELLING Diet and life style Take proper rest. Avoid salty foods such as pickles, fast food and salted nuts. Decrease protein food intake such meat, egg, cheese and milk. Avoid phosphorus rich foods such as chocolate drinks, ice creams and sea foods. Avoid potassium rich foods such as banana, sweet potato and milk. Do mild exercise such as bending legs and move around to avoid blood clots.

17. Drug counseling MEDICINE NAME TIME ROUT OF ADMINISTRATION PRECUATION AND MONITORING M A E N T.Amlong --- Oral Check blood pressure T.Atorax --- --- --- Oral Take only at night T.Revalmer --- Oral Monitor phosphorus level INJ.Epotrust --- --- --- --- IV Only thrice in a week INJ.Calcium gluconate --- --- IV Monitor Calcium & Potassium level INJ.Dextrose --- --- Infusion Monitor blood glucose level NEB.Asthalin Inhalation --- Potassium bind sachet --- Oral by mix with water Monitor potassium level INJ.Taxim --- --- IV --- INJ.Valparin Chrono --- --- --- IV ---

18. T.Atorva --- --- --- Oral Only take at night T.Dolo --- --- --- --- Oral Take when ever necessary and monitor body temperature T.Epilex Chrono --- --- Oral --- T.Levacetam --- --- --- Oral --- INJ.Piptaz --- --- IV --- INJ.CP --- --- IV ---

19. PHARMACIST INTERVENTION Check phosphorus level Check cholesterol level

20. THANK YOU