SOAP format

1. II Pharm . D
REG NO :
381710525.
2018-2019.
1

2. 2

3. 3

4. A 51 year old man was admitted in our KMCH hospital on 23/7/19 as
secondary treatment due to accident in two wheeler on 16/7/19. He was
treated in primary set up on 16/7/19 ICD on both sides and ORIF were done
@palani .HRCT revealed the hydropneumothorax on the right side of the
lung &bronchopleural fistula then numerous bone fractures on the lower
limb. Bronchoscopy and thoracoscopic guided glue injection was planned
for to prevent the air leak in the lungs on 26/7/19.
4

5.  REG NO: 1547418.
 IP NO: F08833.
 AGE & SEX: 51 years old male.
 MARRITAL STATUS: Married.
 DATE OF ADMISSION: 23/7/19 @8:42am.
 DATE OF DISCHARGE: 31/7/19 @2:50pm.
 PRIMARY CONSULTANTS: Dr. Santha kumar (pulmonologist) &
Dr. DMI. Saravana (cardiologist).
 RTA : 2wheeler vs 2wheeler on 16/7/19 primarily treated in native place.
5

6.  Present diagnosis: Rt. Hydropneumothorax.
 Previous procedure surgery: ICD ORIF Done on 16/7/19.
 Provisional diagnosis: COPD & bronchopleural fistula.
 Multiple conditions :
Rt. Intertrochanteric fracture (ORIF).
Rt. Metatarsal fracture.
Flial chest.
 Procedure’s undergone: (previous)
Rt. ICD persistent air leak .
Lt. ICD removed.
6

7. 7
ORIF: open reduction internal fixation.
Internal plates(internal splints)
and screws were placed.

8. 8
Social history: smoker & alcoholic.
Past history : No comorbidities.
Family history: No comorbidities.
Drug allergy : No history of known drug allergy.
1 pack year= 1/2pack/day X 1 yr
= 10 cigarettes/1/2pack
=10X 365.24packs
= 3652.4cigarettes.

9. 9

10. Suggested to perform:
ABG ,CBC, ESR, Urea ,Creatinine, Na+, K+, HRCT, RBS,
HIV- ELISA, PT/INR, ECHO.
ECHO report:
 No regional wall motion abnormality.
Normal LV systolic function.
Trivial mitral regurgitation.
Mild and Moderate pulmonary arterial hypertension(RVSP- 50mmHg).
Inferior vena cava 1.9cm dilated.
No pulmonary embolism/clot.
10

11. 11
contents 23/7/19 24/7/19 25/7/19 26/7/19 27/7/19 28/7/19 29/7/19 30/7/19
Hb 7.8g/dL 7.4g/dL 7.6g/dL 7.6g/dL 7.8g/dL 8.4g/dL 8.6g/dL 8.4g/dL
Tc(cells/cumm) 13900cells/cumm.
Total RBC ↓2.62million/mm3
DC P
L
E
B
M
↑74%
↓21%
02%
00%
03%
PCV ↓22.6%
MCV 86.4fL
MCH 29.9pg/cell.
MCHC 34.6g/dL
ESR(mm/hr) ↑76mm/hr
Platelet 363000cells/µl
Urea -
creatinine 0.5mg/dL

12. 12
content 23/7/19
Sodium 137mEq/L
Potassium 4.8mEq/L
HIV Negative
Blood group &Rh typing O+
Prothrombin Pt value -16.
Control -12 sec.
INR -1.43.

13. DATE TIME HR(beats/min) RR(breaths/min) BP (mmHg) %SpO2(with O2)
23/7/19 12:50am
6:00pm
10pm
92(beats/min)
96(beats/min)
98(beats/min)
24 (breaths/min)
22(breaths/min)
26(breaths/min)
100/90(mmHg)
130/80(mmHg)
130/90(mmHg)
100
99
97
24/7/19 6am
10pm
2pm
6pm
10pm
82(beats/min)
102(beats/min)
100(beats/min)
108(beats/min)
112(beats/min)
22(breaths/min)
24(breaths/min)
24(breaths/min)
22(breaths/min)
26(breaths/min)
110/60(mmHg)
100/60(mmHg)
100/80(mmHg)
120/70(mmHg)
120/80(mmHg)
97
96
97
98
98
25/7/19 2am
6am
10am
2pm
6pm
10pm
116(beats/min)
100(beats/min)
114(beats/min)
120(beats/min)
112(beats/min)
100(beats/min)
28(breaths/min)
26(breaths/min)
22(breaths/min)
22(breaths/min)
20(breaths/min)
20(breaths/min)
130/90(mmHg)
130/80(mmHg)
120/70(mmHg)
130/90(mmHg)
130/80(mmHg)
110/60(mmHg)
96
97
98
97
98
99
26/7/19 6am
5pm
6pm
7pm
8pm
9pm
10pm
92(beats/min)
86(beats/min)
88(beats/min)
82(beats/min)
84(beats/min)
86(beats/min)
82(beats/min)
24(breaths/min)
22(breaths/min)
22(breaths/min)
20(breaths/min)
20(breaths/min)
22(breaths/min)
20(breaths/min)
120/80(mmHg)
110/80(mmHg)
120/70(mmHg)
110/60(mmHg)
120/80(mmHg)
110/60(mmHg)
120/80(mmHg)
99
100
100
98
99
98
97 13

14. 14
DATE TIME HR(beats/min) RR(breaths/min) BP(mmHg) %SpO2
27/7/19 6am
10am
2pm
6pm
10pm
100(beats/min)
102(beats/min)
100(beats/min)
104(beats/min)
100(beats/min)
26(breaths/min)
22(breaths/min)
20(breaths/min)
22(breaths/min)
24(breaths/min)
110/60(mmHg)
110/70(mmHg)
100/80(mmHg)
110/70(mmHg)
120/80(mmHg)
97%
92%
91%
91%
97%
28/7/19 6am
10am
2pm
6pm
10pm
98(beats/min)
112(beats/min)
106(beats/min)
100(beats/min)
94(beats/min)
22(breaths/min)
22(breaths/min)
24(breaths/min)
22(breaths/min)
22(breaths/min)
110/60(mmHg)
110/80(mmHg)
120/80(mmHg)
110/70(mmHg)
110/70(mmHg)
98%
96%
96%
97%
97%
29/7/19 6am
10am
2pm
6pm
10pm
116(beats/min)
112(beats/min)
112(beats/min)
110(beats/min)
108(beats/min)
22(breaths/min)
22(breaths/min)
22(breaths/min)
22(breaths/min)
22(breaths/min)
110/70(mmHg)
110/70(mmHg)
110/80(mmHg)
110/70(mmHg)
110/70(mmHg)
100%
96%
96%
97%
98%
30/7/19 6am
10am
2:30pm
6pm
10pm
102(beats/min)
114(beats/min)
116(beats/min)
102(beats/min)
84(beats/min)
22(breaths/min)
24(breaths/min)
26(breaths/min)
24(breaths/min)
20(breaths/min)
130/60(mmHg)
100/70(mmHg)
110/70(mmHg)
120/80(mmHg)
110/70(mmHg)
99%
98%
97%
98%
98%

15. 15
DATE TIME HR(beats/min) RR(breaths/min) BP(mmHg) %SpO2
31/7/19 6am
10am
72(beats/min)
120(beats/min)
20(breaths/min)
22(breaths/min)
110/60(mmHg)
100/70(mmHg)
98%
97%

16. On 23/7/19 @ 8:42am patient admitted in kmch hospital
@11:52am patient history was noted as
 Tachypnoeic . HR: 94beats/min
 ICD Insitu Rt side. RR: 24breaths/min
 S1 S2 heard. SpO2: 100%
 Pulse rate 90. Temp: 100.5F
 BP 140/90mmHg. GRBS: 99mg/dl
 Hb-7.8g/dl.
Provisional diagnosis: Rt. Bronchopleural fistula.
Plan :
 Inj. Zosyn 4.5gm IV 8hrly infusion over 30mins.
Neb. Levolin 0.63 4hrly respules.
Neb. Formonide 0.5mg BD.
Incentive spirometry.
Tab. P650 BD & Inj. Heparin 5000units S/C OD.
16

17. 17

18. 18
On 23/7/19 @3:20pm
Multiple rib fractures
 Right 3rd-10th&left 2nd-6th.
 Right intertrochanteric fracture.
 Right bimalleolar fracture.
 Right 4th proximal phalanx
Surgery done outside on 16/7/19.
Post operative physiotherapy given.
ECG: satisfactory cardiac status.
@5:00pm Dr. santha kumar
patient reviewed : Hb = 7.8g/dL.
PLAN:
Syp. Dexorange 10ml BD.
To do B/L lower limb venous doppler.
inj. Clexane 0.4 S/C BD.
(heparin was stopped)
inj. Tramadol 50mg IV BD.
inj. Emeset 4mg IV BD.
inj. Paracetamol 1gm IV TID
Daily to check Hb.

19. HRCT Scan of lungs:
 moderate right hydropneumothorax.
Left moderate pleural effusion.
Patchy and confluent ground glassing is noted in the bilateral lung fields.
Fractures as detailed.
Doppler study of left lower limb veins:
No evidence of deep venous thrombosis.
19

20. 20
 The patient was diagnosed with hydropneumothorax by the HRCT scan
evidence report.
 The patients ESR was found to be moderately high 76mm/Hr.
 The patients Total RBC count was extremely low to 2.62million/µL
(hemolysis).
 It can be due to accident blood loss and blood vessel injury and bone
marrow damage can also leads to this deadly conditions.
 https://www.medicalnewstoday.com

21. 21
Hydropneumothorax is treated by
ICD and bronchoscopy with glue injection .

22. 22
On 23/7/19 @12: 50pm
 Temp: 98.6F
 Pulse: 92/min
 RR : 24/min
 SpO2: 100%
 BP: 140/90mmHg.
 Pain persists
Total intake = 750ml
Total output= 2300ml
 On 24/7/19 @ 8:55am patient reviewed Plan on 23/7/19:
 Traumatic B/L pneumothorax . Inj. Para 1gram IV
 Right bronchopleural fluid ,flial chest. Inj. Augmentin 1.2 gram IV
 Right hydropneumothorax. Inj. Pan 40mg IV
BP dropped to 110/60. Inj. Emeset 4gram IV
HR dropped to 82beats/min.
RR dropped to 22breaths/min. Total intake = 850ml
%SpO2 is 97% & Temp 98.8F. Total output = 1900ml
Complaint of difficulty in breathing.
Cough with expectoration.

23. On 25th @ 8:45am
 Temp: 99bts/min
 HR: 100bts/min
 RR: 26breaths/min
BP: 130/80mmHg.
%SpO2: 97% with 5 litres of oxygen.
Complaints of : cough with expectoration & difficulty in breathing.
PLAN: D3
 Inj. Zosyn
Inj. Clexane
Neb. Levolin
Neb. Formonide
Syp. Dexorange.
Inj. Tramadol.
Plan for bronchoscopy tomorrow@ 9: 30
incentive spirometry
@4:45pm
inj. Ketorolac 3mg IV in 100ml NS (BD).
23

24.  Under general anaesthesia
bronchoscopy and thoracoscopic for BPF was done.
0.5ml of glue in each segment is injected.
NPO till 4pm. & monitoring vitals every 15mins till 4pm.
To send drain fluid for Antibiotic susceptibility test for bacterial presence of culture detection.
D4 inj. Zosyn
Neb. Levolin continue till 4pm.
Total intake = 900ml
Drain=100ml
Urine=2500ml
Total output = 2600ml.
On 27/7/19 @9:50 am
Patient is feeling better Air leak has been decreased.
Mobilise out of bed ,incentive spirometry ,Stop ketorolac ,restart inj.clexane & high protein diet.
24

25. 25
On 29/7/19 @ 8:45am
complaint of pain at the site of ICD
Not passed stools since 6 days.
Rt. ICD =30ml. No air leak.
On 30/7/19 @ 12:30pm
ICD removed with strict aseptic condition.
PLAN:
Tab. Chymoral forte (TID)
Tab. Myoril 8mg (BD)
On 31/7/19 @8:10am
Minimal pain @ICD site & patient mobilized.
stat dulcoflex 2dose @12pm rectal route.

26. 26

27.  To reduce the pain .
 To reduce the risk and comorbidities.
 To improve the breathing trouble .
 To increase the red blood cell count.
 To prevent from infection.
 To make the patient mobilise cost effectively.
27

28. 28

29. 29
DRUG DOSE ROUTE &
FREQUENCY
TIME START DATE END DATE
Inj. Zosyn 4.5gm IV & TID 2am
10am
6pm 23/7
31/7@6am
Neb. Formonide 0.5mg Inhalation & BD 6am
6pm 23/7
31/7@6am
Tab. P.650 650mg Oral & BD 9am
9pm
23/7@2pm 23/7dose &Route
Changed
Inj. Para 1gm IV & TID 6am
2pm
10pm 23/7
31/7@6am
Inj. Heparin 5000units IV & OD 10am 23/7 23/7
Inj. Clexane 0.4mg S/C & BD 11am
11pm 23/7
24/7
Changed as OD
Inj. Clexane 0.4mg S/C & OD 11am 24/7 31/7@11am
DRUG CHART:

30. 30
DRUG DOSE ROUTE &
FREQUENCY
TIME START DATE END DATE
Neb. Levolin 0.63mg Inhalation & Q4H 2am
6am
10am
2pm
6pm
10pm
23/7
31/7@10am
Prosure protein powder 2tsp Oral & OD 6am 23/7@7pm 27/7 frequency changed
to BD
Syp. Dexorange 10ml Oral & BD 9am
9pm 23/7
31/7@9am
Inj. Emeset 4mg IV & BD 6am
6pm 23/7
31/7@6am
Inj. Tramadol 50mg IV & BD 6am
6pm 23/7
31/7@6am
Inj. Ketoral 30mg IV & BD 8am
8pm 25/7
27/7@8am
Tab. Chymoral forted’s - Oral & TID 9am
2pm
10pm 30/7
31/7@9am

31. 31
C:UsersSRI SHARIKA KUMARDownloadsInhaled corticosteroids plus long-
acting beta2-agonists as a combined therapy in asthma. - PubMed - NCBI.mhtml
PHARMACIST RECOMMENDATION:
https://www.ncbi.nlm.nih.gov/m/pubmed/27877033/

32.  There is no serious drug- drug , drug-food, drug-disease interaction.
 MILD AND FAIR RELIABILITY:
 Ondansetron will decrease the absorption of tramadol.
 Ondansetron will decrease the absorption of acetaminophen.
 Enaxoparin and Toradol administration cause enhanced effect of anticoagulant
property of enaxoparin.
PHARMACIST RECOMMENDATION:
Tramadol is an centrally acting analgesic also triggers the chemoreceptor trigger zone
so that patient have a chance to vomit , so to avoid that aceclofenac and paracetamol
combination or diclofenac combination can be used.
Antiemetics can be omitted from the treatment chart.
http://apm.amegroups.com/article/view/1038/1264
32

33.  What to avoid ? Don’t s
 smoking should be strictly
avoided.
Not to lift more than 3.5kgs
until the fractured bones get
heal.
No heavy physical activity.
 Does:
Take all the prescribed medications without fail.
Take good rest.
Use the spacer and inhaler
as instructed .
Gargle after use of spacers.
 DRUG DETAILS:
Tab. Pan 40mg- should be taken before food.
2hours gap should be given while taking Tab. Pan
& Tab. Cefakind CV 625mg.
Gap of 2mins should be given between the puffs of
spacer.
33

34. stable discharge on 31/7/19@2:50pm (spirometry to continue)
34
Medications Dosage Morning Afternoon Evening Night A/B Food Duration
Tab. Ultracet 37.5mg/325mg 1 0 0 1 AF 1 week
MDI Formonide
via spacer
200 2puffs 0 0 2puffs 1 week
Prosure protein
powder
2scoops in Water Once a day 1 week
Tab. Cefakind
CV
625mg 1 1 0 1 AF 1 week
Tab. Pan 40mg 1 0 0 0 BF 1 week
MDI Levolin 0.5mcg 2puffs 2puffs 0 2puffs 1 week
Syp. Dexorange 10ml 0 0 10ml 1 week

35. 35
 Before the second puff
Give 2mins gap.
 Atlast gargling is necessary to
avoid fungal mouth infections.