2. SOAP ANALYSIS
SUBJECTIVE EVIDENCE
NAME: Mr.XXX
AGE: 63YEARS
SEX: FEMALE
IP NUMBER:149217/14
DATE OF ADMISSION: 16-10-14
DATE OF DISCHARGE: 22-10-14
REASON OF ADMISSION: C/o fever,abdominal
pain,jaundice since 4 months.evening rise in temperature
not associated with chills,rigor,cough,dysurea.
HPI :Abdominal pain more over right upper quadrant of
abdomen,yellow colouration of sclera and urine
3. PAST MEDICAL HISTORY: attained menopause 10
years back
PAST MEDICATION HISTORY: -
PERSONAL HISTORY: mixed diet
4. OBJECTIVE EVIDENCE
ON GENERAL EXAMINATION:
ICTERUS = +VE
SYSTEMIC EXAMINATION
CVS-S1 AND S2 HEARD
RS- NVBS B/L
P/A : DISTENDED
NO LOCAL RISE OF TEMPERATURE
TENDERNESS OVER RIGHT HYPOCHONDRIUM
ABDOMINAL GIRTH -75 CM
P/A: SOFT ,NO ORGANOMEGALY
9. GOALS OF TREATMENT
TO REDUCE THE SIGNS AND SYMPTOMS
TO TREAT THE ASSESED CONDITION AND
REDUCE FURTHER COMPLICATIONS SUCH AS
CIRRHOSIS,ASCITES,HEPATOCELLULAR
CARCINOMA
TO PREVENT THE RE EMISSION OF THE DISEASE
TO IMPROVE THE QUALITY OF LIFE OF PATIENT
13. PROBLEMS IDENTIFIED
PATIENT HAD COMPLAINT OF DYSUREA BUT
WAS NOT TREATED
URINE ANALYSIS CAN BE DONE FOR UTI SINCE
PATIENT PRESENTS WITH ABDOMINAL
PAIN,DYSUREA.
PATIENT HAD COMPLAINT OF FEVER ,NO
TEMPERATURE MONITORING NOR DRUG WAS
GIVEN
15. PATIENT COUNSELLING
DRINK PLENTY OF WATER
DRINK SUGARCANE JUICE WHICH HELPS IN DIURESIS HELPS IN
RELIEVING DYSUREA AND BEST IN JAUNDICE AND LIVER
FUNCTION IMPROVEMENT
AVOID SATURATED FAT IN DIET AND INCLUDE HEALTHY FATS
SUCH AS OMEGA 3 FATS
AVOID HIGH SODIUM DIET THAT MAY CAUSE SODIUM AND
WATER RETENTION AND CAUSE FURTHER COMPLICATIONS
CONSUME PAPAYA,HONEY,PINEAPPLE,AVOCADO THAT ARE RICH
IN DIGESTIVE ENZYMES THAT REDUCE BILIRUBIN LEVELS
CUT DOWN REFINED SUGAR,THAT CAUSES FAT BUILD UP IN
LIVER
AVOID ALCOHOL
FOLLOW MEDICATIONS REGULARLY AND GET REGULAR CHECK
UPS
