Some interesting content :
In case study courses and clinical clerkships, a comprehensive write-up may be many pages long. In the real world of pharmacy practice, a complete patient evaluation may be limited to one or two pages, and progress notes condensed to just a few paragraphs. Progress notes may not use all the modules; however, they should still include at least one pharmaceutical diagnosis. In a progress note the pharmacist may document changes in health problems, update pharmaceutical diagnoses, recommend new orders, document whether outcomes have been attained, report the results of monitoring, or record the success of patient counseling.
Example of case in American Journal of Pharm. Edu :
K.H. is a 52-year-old, 80 kg, 5’7” male who comes to the clinic today 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, and 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.
IF YOU FOLLOW EXPANDED SOAP (Subjective, Objective, Analysis, Plan) FORMAT, YOU MUST HAVE :
2.HISTORY OF PRESENT ILLNESS
3.PAST MEDICAL HISTORY
a)Chronic bronchitis in an acute exacerbation
d)Deep Vein Thrombosis
EXAMPLE OF SOAP FOR DRP NO. 1 (Chronic Bronchitis Exacerbation)
1-CHRONIC BRONCHITIS EXACERBATION
S: K.H. complains of SOB and increased sputum production.
O: K.H. 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. K.H. has a 50 pack-year smoking history.
A: K.H. 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 K.H. 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 metaproterenol 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 500 mg po qid. 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 K.H.’s 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. K.H. should discontinue smoking; refer him to a smoking cessation clinic.