SOAP ANALYSIS- PHARM.D.pptx

The Subjective, Objective, Assessment and Plan (SOAP).the assessment will identify what the drug related/induced problem is likely to be and the reasoning/evidence behind it. This will include etiology and risk factors, assessments of the need for therapy, current therapy, and therapy options.

1. CASE PRESENTATION ON COSTOCHONDRITIS Vineeth Vidhyasagar. P, I17060036, 5 th Pharm.D, Department of Pharmacy, AU.

2. C/O: Patient bought to causality with C/O chest pain for 2 days Radiating to back , both sides. Compressive in nature. No H/O breathlessness/ palpitation/ giddiness/ set vomiting/ diarrhea K/C/O SHTN & Angina, Cag Done @ 6months back O/E: Patient conscious, oriented, afebrile. No P - / I - / C - / C - / L - BP – 130/80 mm/Hg PR- 74 / Min SpO2 – 98% @ RA RR- 18/min Name: Ambika Ward: Medicine Age : 47 years Unit: M1/22 Sex : Female IP.No : 895804

3. S/E: CVS- S 1 S 2 + RS – B/L AE + NVBS + CNS – NFND P/A – Soft, BS + INVESTIGATION: CBC: Hb-11.6g/dl TC – 10800 Cells/cu.mm Plt – 3.83 Lakhs Cells/cu.mm 2) ESR 7mm 5mm 3) RBS - 101 mg/dl 4)RFT : S.Urea – 21 mg/dl S.Creatinine – 0.8 mg/dl 5 ) S.Electrolytes : S.Na + – 141 mmol /L S.K + – 4 mmol /L S.Cl - – 101 mmol /L 6) LFT: Bilirubin (T) - 0.9 mg/dl (P) - 0.2 mg/dl (L) – 0.6 mg/dl SGOT : 29 U/L SGPT : 21 U/L ALP : 89 U/L 7) S.Proteins : S.Alb – 3.5 gm/dl T.Protein – 6.7 gm/dl S.Globulin – 3.2 gm/dl 8) CXR – PA view 9) 2D Echo : - concentric LVH - Grade I s ystolic dysfunction - Adequate LV systolic Function - No resulting RWHA - No significant pain

4. TREATMENT : T.Aspirin – 325 mg Stat T. Clopidogrel 300 mg Stat T.Atorvas 80 mg Stat Inj.Heparin 5000 U IV stat T.Envas 5 mg (1-0-1) Syp . Creamaftin 15 ml HS PROVISIONAL DIAGNOSIS : 1)ACS – Unstable Angina 2)Systemic Hypertension FINAL DIAGNOSIS : 1) Costochondritis 2)Systemic Hypertension 7. T.Clonazepam 0.25 mg ( 0-0-1) 8. T.ISDN 2.5 mg stat 9. T.Ultracet ( 0-0-1) 10. Inj . Emeset 4mg IV BD 11. Inj.PAN 40 mg IV BD 12. T.Zerodol P (1-0-1) 13. T.Myospar Forte (1-0-1 )

5. SOAP ANALYSIS SUBJECTIVE: Patient bought to causality with C/O chest pain for 2 days Radiating to back , both sides. Compressive in nature. K/C/O SHTN & Angina OBJECTIVE: ECG – V1V2 T.Wave , III avf T.wave  2D Echo : concentric LVH Grade I systolic dysfunction Adequate LV systolic Function No resulting RWHA No significant pain

6. ASSESMENT : Based on the lab investigations and the patient’s complaints it is confirmed that the patient is having “COSTOCHONDRITIS” PLAN BRAND NAME GENERIC NAME CATEGORY DOSE R.O.A FREQUENCY T.Aspirin Aspirin Anti-coagulant 325 mg PO OD T.Clopidogrel Clopidogrel Anti-platelet 300 mg PO OD T.Atorvastatin Atorvastatin Statins 80 mg PO OD Inj.Heparin stat Heparin Anti-coagulant 5000 U IV OD

7. BRAND NAME GENERIC NAME CATEGORY DOSE R.O.A FREQUENCY T.Clonazepam Clonazepam CNS Depressant 0.25 mg PO OD Syp.magnesium hydroxide Mg.hydroxide Laxative 15 ml PO OD T.Isosorbide dinitrate T.Isosorbide dinitrate Nitrates 2.5 mg PO OD T.Tramadol Tramadol Analgesics 25 mg PO BD Inj.pantoprazole Pantoprazole Proton pump inhibitor 40 mg IV OD Inj. Ondansatron Ondansatron Anti emetic 4 mg IV BD T.Aceclofenac Aceclofenac Analgesics 200 mg PO BD T.Clorozoxozone Clorozoxozone Analgesics 250 mg PO BD

8. CRITICAL EVALUATION OF THE PRESCRIPTION QUESTIONNAIRE YES NO Needing pharmacotherapy and not receiving it - 🗸 Taking or receiving the wrong drug - 🗸 Taking or receiving too little of the drug content - 🗸 Experiencing drug - drug interactions 🗸 - Not taking or receiving the prescribed drug - 🗸 Taking or receiving a drug for no valid indication - 🗸

9. GOAL OF THERAPY: The main goal of anti-hypertensive drug is to treat or prevent CVS damage The goal is to reduce high BP and protect vital organs DRUG INTERACTION: CLOPIDOGREL + PANTOPRAZOLE Serum concentration of active metabolites of Clopidogrel can be reduced when Clopidogrel is used in combination with pantoprazole resulting in loss in efficiency HEPARIN + ACECLOFENAC Aceclofneac increases the anti coagulant activity of heparin, but the frequency of both the drug changes. So there is no drug drug interaction

10. PATIENT COUNSELLING Follow the medical advice Quit smoking & Consuming Alcohol Heat pads. Ice application. Acupuncture . Gentle stretching exercises. Avoidance of sports or activities that worsen the pain. Physiotherapy or chiropractic therapy to help loosen up the rib cage.