Soap analysis on PNEUMONIA: By RxVichuZ!

This powerpoint deals with the SOAP analysis of Pneumonia, suffered by a girl, how the disease was diagnosed & appropriate treatment measures given & patient counselling tips given.

Regards,
@ RxVichu!! :)

1. SOAP ANALYSIS ON PNEUMONIA REG NO: 132820210

2. PROBLEM LIST: “Left Lower Lobe Pneumonia”

3. SUBJECTIVE DETAILS: PATIENT DETAILS: NAME : Ms. Y Age : 17 yrs Sex : F I.P No: 197121 Department : GM Weight: 58 kg Height: 165 cm BMI: 21.303 DOA : 19/10/2016 DOD: 27/10/2016

4. 2. REASON FOR ADMISSION: Patient had c/o: Cough for 2 weeks Pleuritic chest pain for 2 weeks Headache(occurred 2 weeks back, and lasted for 5 hours) 3. PAST MEDICAL HISTORY: Not significant 4. FAMILY HISTORY : Not significant 5. SOCIAL HABITS: Non-smoker Non- alcoholic

5. 6. KNOWN ALLERGIES : Nil 7. FOOD HABITS: Non-vegetarian

6. OBJECTIVE DETAILS: VITALS CHART : DATE 19/10 20/10 21/10 22/10 23/10 24/10 25/10 26/10 27/10 TEMP. 100 99 N 99 N N N N N B.P 120/70 130/80 110/70 130/90 120/70 120/70 130/90 120/90 110/90 PULSE 88 90 106 80 84 88 86 90 92 RBS 115 RR 22 20 20 20 24 22 20 24 24

7. 2. BLOOD COUNTS: Hb : 12 g/dl ESR: 15 mm/ hr Platelet count: 2.47 lakhs WBC : 10,140 cells/ cumm DLC: Neutrophils: 80.5% Lymphocytes: 13.5% Monocytes : 5.2 % Eosinophils: 0.5% Basophils: 0.2%

8. 3. LFTs: Total bilirubin: 0.30 mg% Direct bilirubin: 0.01 mg% Albumin: 3.72 mg/dl ALP: 48 IU/L SGPT: 10 IU/L SGOT: 18 IU/L Total protein: 6.74 mg% Globulin: 3.02 mg%

9. 4. RFTs: Urea: 17.03 mg% Uric acid: 4.28 mg/dl SCr : 1.03 mg% 5. ELECTROLYTES: (In mEq/L) Sodium: 135 Potassium : 4.0 Calcium: 9.6 6. OTHERS: Coarse creps in infrascapular & interscapular area CNS: WNL GIT: Soft, non-tender. . .

10. ASSESSMENT: DIAGNOSIS: “Left lower lobe pneumonia” 2. ASSESSMENT, IF THERAPY INDICATED: To alleviate signs and symptoms To avoid complications To reduce ADRs , associated with therapy To improve HRQoL. . .

11. 3. ASSESSMENT OF CURRENT THERAPY: Drugs given to the patient, involve: INJ. MONOCEF(CEFTRIAXONE) ; 1g i.v; Q12H (D1 & D4): 3 rd generation cephalosporin, bactericidal in nature, by working against cell wall synthesis Covers major spectrums of GRAM NEGATIVE ORGANISMS ii. T. ZITROBACT(AZITHROMYCIN), 500 mg P/O, OD, (D1-D4): INTIAL DRUG OF CHOICE, as it covers MOST OF PNEUMONIA ETIOLOGICAL AGENTS, INCLUDING MYCOPLASMA SPECIES Has LESSER ADRs, compared to other drugs used under this disease

12. iii. T.PAN (PANTOPRAZOLE) ; 40 mg, P/O, OD, (D1-D9): Proton-pump inhibitor Has been used to act on GI parietal cells to prevent damages to GI epithelium due to excess acid production, as a tantamount of antibiotics used in the patient. iv. T.DOLO (ACETAMINOPHEN); 650 mg; P/O; (D1-D5): Helps to reduce fever, and also to alleviate pain(justifiable by the patient having slightly raised temperature in initial days of admission, along with chest pain and headache). v. INJ. TAZOMAC (PIPERACILLIN+ TAZOBACTAM) , 4.5 g , i.v, Q8H (D4-D9): Effective, since it is ANTI-PSEUDOMONAL , coupled with BETA-LACTAMASE INHIBITOR

13. vi. CAP. DIPEP(PEPSIN + CELLULASE + FUNGAL DIASTASE+ PAPAIN) , 10 mg, 1 capsule per day, (D5-D9): Has many implications, but here its used to improve digestion, and enhance affinity towards having good meals. vii. T. MOXIF( MOXIFLOXACIN) , 400 mg P/O, BD(D3-D9): Fluoroquinolone antibiotic(4 th generation) bactericidal, that disrupts bacterial DNA replication

14. PLAN (TREATMENT CHART): DRUG NAME DOSE 19/10 20/10 21/10 22/10 23/10 24/10 25/10 26/10 27/10 Inj. Monocef 1 g i.v Q12H Y Y T . Zitrobact 500 mg P/O , OD Y Y Y Y T. Pan 40 mg P/O Y Y Y Y Y Y Y Y Y T. Dolo 650 mg P/O, TID Y Y Y Y Y Inj.Tazomac 4.5 g i.v Q8H Y Y Y Y Y Y C. Dipep 1 cap OD Y Y Y Y Y T. Moxif 400 mg, P/O , BD Y Y Y Y Y Y Y

15. PROGRESS CHART: 19/10/16: Patient was febrile Chest showed coarse creps on left interscapular & infrascapular areas 2. 20/10/16: Temperature slightly reduced Patient had c/o consistent cough 3. 21/10/16: No fresh complaints Febrile 4. 22/10/16: - No fresh complaints

16. 5. 23/10/16: No fresh complaints 6. 24/10/16: Febrile No fresh complaints C/0 indigestion 7. 25/10/16: No fresh complaints 8. 26/10/16: No fresh complaints 9. 27/10/16: - No fresh complaints, the patient felt better, and was discharged appropriately. . .

17. DISCHARGE SUMMARY: “ A 17 year old girl, with no other co-morbidities, presented with COUGH, PLEURITIC CHEST PAIN(for 2 weeks), and HIGH GRADE FEVER (for 2 days). On observation: Conscious, oriented, patient was febrile, creps (+ ve ), X-ray chest done. Patient was treated with i.v antibiotics . Patient was found to improve symptomatically. CT-thorax was planned. Patient was found to be better, and was discharged appropriately.”

18. DISEASE-RELATED COUNSELLING: Focus on the following remedies: Cayenne pepper Turmeric Black pepper Garlic Ginger Sesame seeds Fenugreek seeds. . .

19. POINTS TO BE MONITORED: PIPERACILLIN + TAZOBACTAM : Monitor for LFTs, (AST & ALT levels) Perform urinalysis and BUN and creatinine levels measurements during therapy 2. MOXIFLOXACIN : Use, with CAUTION, for PROLONGED THERAPY, since they are associated with SUPERINFECTIONS with prolonged/ repeated therapy May also cause TENDONITIS/ MUSCLE RUPTURES. . .

20. THANK YOU !!!!