Soapo on pneumonia, subjective , objective , assessment,plan outcome

1. PATIENT CASE PRESENTATION
(SOAPO)
Infectious Diseases: Pneumonia
Israel A. Sefah
(Specialist Pharmacist)

2. OUTLINE
 OBJECTIVES
 INTRODUCTION TO SOAPO
 CASE PRESENTATION
 CONCLUSION
 REFERENCES

3. Objectives
 Student learn will understand the components of SOAPO
 Student will learn how to apply SOAPO
 Student will learn how to give case presentation using
SOAPO format

4. Introduction to SOAPO
 Acronym for subjective, objective, assessment, plan and
outcome
 SOAPO note is a patient medical record written/ presented in
specific order
 It originated from problem-oriented medical record
developed by Lawrence Weed (MD)

5. Introduction to SOAPO
 It consist of five sections
 It’s purpose is to have standard format for organizing patient
information
 Subjective section refers observation that are verbally
expressed by patient (complaints and its history )
 Objective section refers to factors clinician can measure, see,
feel, hear or smell (signs)

6.  It includes vitals (TPR), physical exams, diagnostic test results
(lab, scan, x-ray)
 Assessment section deals with confirmation of diagnosis
(main and differential) and treatment analysis (drug-related
problems)
 Plan section deals with how to manage the patient problem
achieve optimum outcome (treatment, interventions, efficacy
and toxicity monitoring)
 Outcome section deals with clinical outcome and status of
intervention

7. Patient profile
Patient
Initials
F. A. Date: DOB 42yrs Sex : F
Ward : A&E trans to
Female
Ethnic Origin Ewe Weight: 62kg
Religion: Christianity Insurance : Non-
Insured
Occupation: Hairdresser Marital status Married
Address Agbakorfe

8. Patient profile (cont’d).
 Presenting Complaint
(12/2/2019).
 Headache
 Throat pain
 Cough
 chest pain
 difficulty in breathing
 History of Presenting Complaint
 Apparently well until 2 days ago
 Started experiencing cough,
sneezing, difficulty in breathing and
headache 4 days ago.
 Took paracetamol tablets and cough
mixture but condition worsened.
 She was brought to the hospital
Accident and Emergency Department
accompanied by a relative in a
distressed stage

9. Patient History
ODQ
The following were present: Dizziness, Cough,
Generalized bodily pains including chest pain,
throat pain and nasal congestion
The following were absent: Chills, bitterness in the
mouth, neck stiffness

10. Patient History
Social History: Hairdresser, Non-alcoholic, Not a smoker
Past Medical History: A known Hypertensive on treatment
Family History: Nil of note
Past Drug History: Paracetamol tablet, Cough syrup,
Nifedipine tablets.
Allergies: No known allergy.

11. Physical examination findings
O/E
A middle aged woman (42 years), ill looking seen in the A & E ward,
febrile (38.5 °C), warm to touch, pallor (-) jaundice (-), dyspnea (+),
hydration (fair).
CVS: S1+S2 +M0 , Palpitation Pulse: 86 bpm BP: 136/80mmHg
CNS: Conscious, No blurred vision
Chest: A/E Reduced bilaterally B/S: crackles on auscultation.
Musculoskeletal: Joint pain (+), heart burn (+), vomiting (-), diarrhea (-
), abdominal pain (-)
Respiratory: RR: 32 cpm SPO2 90%

12. Investigations
RENAL FUNCTION TEST (20/08/2018)
Test Result Unit Flag Reference Range
Urea 8.5 mmol/L H 1.7-8.3
Creatinine 115 µmol/L H 40-110

13. Investigations (cont’d)
 Chest X-ray (12/2/19)
 Bilateral patchy imfiltrates
 RETROSCREENING and GeneXpert
 Retro-screen non-reactive
 Client could not produce sputum for screening for Acid Fast Bacilli.

14. Investigations (cont’d) FBC results (21/11/18)
Test Result Unit Flag Reference
Range
WBC 13.40 103/µL H 5.0-11.60
LYM% 12.50 % 19.1-48.5
MID% 16.30 % H 4.5-12.1
GRA% 80.20 % H 43.6-73.4
LYM 1.38 103/µL 1.30-4.00
GRA 5.53 103/µL 2.40-7.60
HGB 12.3 g/dl 11.50-15.1
MCH 28.10 pg 27.5-32.4
MCHC 32.40 g/dl 31.7-34.2
RBC 4.34 106/µL 3.79-5.14
MCV 85.70 fL 84.0-98.0
HCT 38.40 % 34.00-45.40
PCT 0.23 % 0.16-0.36
MPV 8.7 fL L 8.3-12.1

15. Patient vital chart
Date BP (mm/Hg) Heart Rate (bpm) SPO2% Temp ᵒC RR cpm
12/2/19 136/80
132/79
86
82
90 38.5
38.2
32
13/2/19 130/82
132/82
90
96 on O2
38.3
37.8
31
14/2/19 125/78
130/80
98 on O2
96
37.5
37.3
27
15/2/19 126/82
132/80
36.7 23
19
16/2/19 130/75
135/76
18
17/2/19 130/80
128/78
18/2/19 130/78
12879

16. Current medications
Medication and Strength Route Start Date Dose, Dosage Indication End Date
IV Amoxicillin +
acid 1.2g
IV 12/2/19 1.2g TID x 48 hrs Pneumonia,
Pharyngotonsilitis
13/2/19
Inj Gentamycin 80mg I.M 12/2/19 80 mg TID x 48hrs Pneumonia 13/2/19
Tab Azithromycin Oral 13/2/19 500mg daily x 7 Pneumonia 19/2/19
Tab Ibuprofen Oral 12/2/19 400mg TID x 5 Throat pain and
Headache
17/2/19
Inj Tramadol IV 12/2/19 100mg Stat Persistent Headache 12/2/19
Inj Tramadol in Normal
Saline
IV 13/2/19 100mg Stat Persistent Headache 13/2/19
IV Amoxicillin +
acid 1.2g
IV 14/2/19 1.2g TID x 48 hrs Pneumonia 16/2/19
Tab Ascorbic acid 100mg Tab 12/2/19 100mg TID x 7 Pharyngotonsilitis 19/2/19
IVF Dextrose Saline IV 12/2/19 1L Hydration 12/2/19
IVF Ringer Lactate IV 12/2/19 1L Hydration 12/2/19
Tab Amoxiclav Tab 12/2/19 625mg BD x 5 Pneumonia 17/2/19

17. Medical problems
 Bronchopneumonia
 ?Pharyngotonsilitis
 Hypertension

18. PHARMACEUTICAL CARE ISSUES
 Inappropriate selection of antibiotic
 Inadequate antibiotic coverage
 Potential adverse drug reaction (mild renal impairment and
gentamycin)
 Inappropriate reconstitution of parenteral antibiotic

19. Pharmaceutical care plan (SOAPO)

20. OPTIMIZING THE TREATMENT OF COMMUNITY
ACQUIRED PNEUMONIA
SUBJECTIVE DATA
 Dyspnoea
 Cough
 Fever
 Chest Pain
OBJECTIVE DATA
 Patchy infiltrates (x-ray)
 Temperature (38.5 oC)
 SPO2 90%
 Palpitation
 Pulse: 86bpm
 RR: 32 cpm

21. ASSESSMENT
Diagnosis confirmation:
 CURB-65 score >2 (admit)
 Additional factors: SPO2<92%
 Both objective and subjective findings confirm diagnosis
Treatment Objectives of Pneumonia
 Identify patient at greater risk who require in-hospital management
 To alleviate symptoms
 To treat and eradicate infection
 To prevent and/or manage complications

22. ASSESSMENT
Medications
 Inj. Amoxicillin + Clavulanic acid 1.2g tid x 48 hours -
RECOMMENDED
 Inj. Gentamycin 80mg tid * 48 hours - WITHDRAWN
 Oxygen therapy - RECOMMENDED

23. PLAN
Prescription
 Oxygen
 Inj. Amoxicillin +
Clavulanic acid 1.2g bd
* 48 hours
 Inj. Gentamycin 80mg
tid * 48hours
Interventions/Recommenda
tion
 Gentamycin was recommended to
be withdrawn
 Azithromycin was added to therapy
 Pharmacist educated and helped in
the reconstitution of Inj. Amoxiclav
in the ward

24. Monitoring
EFFICACY TOXICITY
Oxygen raising SPO2
above 92%
Confusion, anxiety
Inj Amoxicillin +
Clavulanic acid
Temperature,
WBCs
Hypersensitivity
reactions
Tab Azithromycin Temperature,
WBCs
Nausea, Vomiting,
Abdominal
discomfort

25. OUTCOME
Interventions were accepted, patient condition
improved and was discharged
Discharge adherence counselling on the need to
complete oral antibiotics after discharge

26. Conclusion
 SOAPO note format is a useful standard medical case
presentation format
 It is widely adopted as a communication tool to document a
patient's progress.

27. REFERENCES
1. BNF (2019-2019). British National Formulary (Vol. 76): Royal
Pharmaceutical Society,.
2. Weed, Lawrence L. (June 1964). "Medical records, patient care, and
medical education". Irish Journal of Medical Science. 39 (6): 271–
282.
3. MoH. (2017). Standard Treatment Guidelines (7 ed.): Ghana National
Drugs Programme.
4. NICE. (2018). Pneumonia in adults: diagnosis and management:
National Institute for Health and Care Excellence.