PATIENT PROFILE FORM AND SOAP

NOTES-08
FILE NO.: 231 IP NO.: MSR24IP1723
PATIENT’S NAME: Mrs. XYZ UHID: 1400007586
GENDER: Female DOA: 22-06-2024,09.34 PM
AGE: 36 years DOD: 24-06-2024, 05.48 PM
CHIEF COMPLAINTS: Fever associated with CHILLS, BODY PAINS, JOINT PAIN
HISTORY OF PRESENTING ILLNESS: Patient presented with h/O moderate to high grade fever for 5
days associated with chills, body pains, joint pains, afebrile for 2 days. c/o generalised weakness, fatigue
with nausea sensation. No H/o vomitings, sob, chest pain, abdominal pain, loose stools, burning mituration,
syncope, rashes.
PAST MEDICAL HISTORY: NIL
PAST MEDICATION HISTORY: NIL
ALLERGIES: NIL
GENERAL EXAMINATION:
• BP: 110/60 mm Hg TEMP: 97.9°F
• PR: 65 bpm GRBS: 102 mg/dl
• RR: 20 cpm SPO2: 99% @RA
• PICCLE: -ve
SYSTEMIC EXAMINATION:
• CVS: S1, S2 heard, no murmurs
• CHEST/RS: B/L Air entry+, no added sounds.
• P/A: Soft. Non-tender.
• HEENT: NAD
• CNS: NFND
• SKIN/EXTREMITIES: NAD
LABORATORY INVESTIGATIONS:
COMPLETE BLOOD COUNT(CBC)
TEST NAME RESULT UNIT REFERENCE INTERVAL
Haemoglobin 13.3 g/dL 12 - 15
Packed Cell Volume 41.1 % 36 - 46
Total Count 6390 cells/cu mm 4000 - 11000
RBC Count 5.00 million/cumm 3.8 - 4.8
Mean Corpuscular Volume 82.2 fL 83 - 101
Mean Corpuscular Haemoglobin 26.6 pg 27 - 32
Platelet Count 29000 /ul 150000 - 410000
Neutrophils 22.6 % 40 - 80
Lymphocytes 64.8 % 20 - 40
Monocytes 10.2 % 2 - 10
ABSOLUTE NEUTROPHIL COUNT 1450 cells/cmm 2000 - 7000
ABSOLUTE LYMPHOCYTE COUNT 4140 cells/cmm 1000 - 3000
ABSOLUTE MONOCYTE COUNT 650 cells/cmm 200 - 1000
ABSOLUTE EOSINOPHIL COUNT 120 cells/cmm 20 - 500
 PLATELET COUNT

TEST NAME RESULT UNIT REFERENCE INTERVAL

Platelet Count 38000 /ul 150000 - 410000

FINAL DIAGNOSIS: Based on the subjective and objective evidence, the patient was diagnosed
with DENGUE FEVER WITH THROMBOCYTOPENIA.

MEDICATION CHART:
Generic Name
Brand Name Frequency Dose/Volume Schedule Duration
RL
RINGER LACTATE) EUROHEAD SOS 500ml - 3 days
500ML
DEXTROSE DNS 500 ML
ANHYDROUS+SODIUM SOS 500ml - 3 days
CHLORIDE
PRASOPHEG Morning,
PANTOPRAZOLE BID 40mg 3 Days
40MG INJ Night
ONDAFINE Morning,
ONDANSETRON INJ TID 4mg Afternoon, 3 Days
Night
AEQUIMOL
PARACETAMOL SOS 1g - 3days
100ML

PATIENT PROGRESS NOTES:

24 June 2024, 11:30 AM:
Patient is stable and has shown improvement. No fever noted. Appetite has improved. No urinary symptoms
reported. No complaints of rash, abdominal pain, or vomiting.
• Temperature: Afebrile (normal temperature).
• Vitals: Stable; specific vital signs not detailed but noted as stable.
• Cardiovascular System (CVS): S1, S2 present and normal.
• Respiratory System (RS): Bilateral lung air entry (B/LAE) present.
• Abdomen (P/A): Soft, bowel sounds positive (BS+).
23 June 2024, 01:59 PM
• Condition: Stable, afebrile, no rash, abdominal pain, or vomiting.
• Advice: Continue current medication; platelet count to be checked in the evening; CBC
review scheduled for the next morning.
22 June 2024, 11:58 PM
• Condition: Stable; conscious, oriented. Presented with fever, chills, body aches, and joint
pain.
• Diagnosis: Dengue fever with thrombocytopenia.
• Treatment: Symptomatic management, monitor vitals, CBC tomorrow, and follow ER
treatment as per chart.
22 June 2024, 09:38 PM
• Provisional Diagnosis: Dengue fever with thrombocytopenia.
• Initial Treatment: IV fluids, injection Pan, injection Emeset, injection PCT as needed.
DISCHARGE MEDICATIONS:
CAP SOMPRAZ D 1-0-1 X 5 DAYS (BEFORE FOOD)
TAB DOLO 650MG SOS
CAP BECOSULES 0-1-0 X 1 WEEK

SOAP ANALYSIS:
SUBJECTIVE EVIDENCE:
• Name: Mrs. XYZ
• Age: 36 years
• Gender: Female
• DOA: 22/6/24
• DOD: 24/6/24
• CHIEF COMPLAINTS: Fever associated with CHILLS, BODY PAINS, JOINT PAIN
• HISTORY OF PRESENTING ILLNESS: Patient presented with h/O moderate to high grade
fever for 5 days associated with chills, body pains, joint pains, afebrile for 2 days. c/o generalised
weakness, fatigue with nausea sensation. No H/o vomitings, sob, chest pain, abdominal pain, loose
stools, burning mituration, syncope, rashes.
• PAST MEDICAL HISTORY: Nil
• PAST MEDICATION HISTORY: Nil
• ALLERGIES: NIL

OBJECTIVE EVIDENCE:
GENERAL EXAMINATION:
• BP: 110/60 mmhg
• PR: 65/min
• TEMP: 97.4°F
• RR: 20 min
• SPO2: 99% on RA.
• CVS: S1 and S2 heard, no murmurs
• Chest/RS: B/L NVBS +ve,no added sounds
• P/A: Soft, non-tender
• CNS: Normal, patient is conscious and oriented
• Skin and Extremities: NAD
• HEENT: NAD
• Platelet Count: 29000 /ul
• Neutrophils: 22.6 %
• Absolute Neutrophil Count: 1450 cells/cmm
• Absolute Lymphocyte Count: 4140 cells/cmm
• Mean Corpuscular Volume: 82.2 fL
• Mean Corpuscular Haemoglobin: 26.6 pg
• Monocytes: 10.2 %

ASSESSMENT:
Subjective data Objective data

• Fever associated with CHILLS, BODY • Platelet Count: 29000 /ul

PAINS, JOINT PAIN • Neutrophils: 22.6 %
• Patient presented with h/O moderate to • Absolute Neutrophil Count: 1450
high grade fever for 5 days associated cells/cmm
with chills, body pains, joint pains,
 afebrile for 2 days. c/o generalised • Absolute Lymphocyte Count: 4140
weakness, fatigue with nausea sensation. cells/cmm
No H/o vomitings, sob, chest pain, • Mean Corpuscular Volume: 82.2 fL
abdominal pain, loose stools, burning • Mean Corpuscular Haemoglobin: 26.6 pg
mituration, syncope, rashes. • Monocytes: 10.2 %
•
•

FINAL DIAGNOSIS: Based on the subjective and objective evidence, the patient was diagnosed
with DENGUE FEVER WITH THROMBOCYTOPENIA

PLAN:

1. General Management:
• Hydration: Ensure adequate fluid intake to prevent dehydration. Oral rehydration solutions
or IV fluids may be needed if oral intake is insufficient or if there are signs of dehydration.
• Rest: Encourage bed rest to help the body recover and conserve energy.
• Monitoring: Regularly monitor vital signs, especially blood pressure and pulse, to detect any
signs of shock or deterioration. Monitor platelet counts and other relevant laboratory
parameters.
2. Symptomatic Management:
• Fever Management:
o Antipyretics: Acetaminophen (Paracetamol) is recommended for fever and pain
relief. Avoid NSAIDs (e.g., ibuprofen) as they can exacerbate bleeding risks.
• Pain and Joint Pain Relief:
o Acetaminophen: Effective for pain relief without the bleeding risks associated with
NSAIDs.
3. Laboratory Monitoring:
• Platelet Count: Regular monitoring of platelet count is crucial to assess the risk of bleeding
and the need for any potential interventions.
• Hematocrit Levels: Monitoring is important to identify any signs of bleeding or plasma
leakage.
4. Dietary and Lifestyle Recommendations:
• Diet: Maintain a nutritious diet rich in vitamins and minerals to support recovery. Encourage
consumption of easily digestible foods and plenty of fluids.
• Avoid: Recommend avoiding any medications or supplements that could potentially worsen
bleeding risk, such as NSAIDs or certain herbal remedies.
5. Complications Management:
• Bleeding: Monitor for any signs of bleeding such as gum bleeding, easy bruising, or blood in
stool or urine. If bleeding occurs or if platelet counts drop significantly, consider possible
transfusion options or other interventions as per clinical guidelines.
Source: Patterson J, Sammon M, Garg M. Dengue, Zika and chikungunya: emerging arboviruses in
the New World. Western Journal of Emergency Medicine. 2016 Nov;17(6):671.
 MEDICATION HISTORY INTERVIEW- 08
A 36-year-old female came to the General OPD with chief complaints of Fever associated with chills,
body pains, joint pain.
Clinical Pharmacist: Good morning, Mrs. XYZ. I’m [Pharmacist’s Name], a clinical pharmacist. I’d
like to ask you some detailed questions to better understand your symptoms and help with your
treatment. Can you tell me more about when your symptoms started and how they have progressed
over time?
Mrs. XYZ: Good morning. My fever started about five days ago. It’s been fluctuating between high
and moderate. The chills and body aches began around the same time, and the joint pain came on a bit
later.
Clinical Pharmacist: I see. Have you noticed any specific patterns with your fever, such as certain
times of day when it worsens or improves?
Mrs. XYZ: It tends to be worse in the evenings and gets a little better in the mornings.
Clinical Pharmacist: Thanks for that detail. Have you had any recent changes in your daily routine,
diet, or exposure to new environments?
Mrs. XYZ: No major changes, but I did start a new job a few weeks ago. It’s been quite stressful, and
I’ve had less sleep than usual.
Clinical Pharmacist: Stress and lack of sleep can sometimes impact your health. Regarding your
joint pain, can you specify which joints are affected and if there’s any swelling or redness?
Mrs. XYZ: The pain is mostly in my knees and elbows. There’s no noticeable swelling or redness,
just pain and stiffness.
Clinical Pharmacist: Understood. You mentioned feeling weak and fatigued. Can you describe how
this has affected your daily activities? For example, has it impacted your ability to work or perform
daily tasks?
Mrs. XYZ: Yes, I’ve been feeling too weak to go to work and even simple tasks like cooking or
cleaning have become difficult.
Clinical Pharmacist: That sounds challenging. Have you experienced any weight loss, changes in
appetite, or difficulty eating?
Mrs. XYZ: I haven’t lost weight, but I’ve definitely had a reduced appetite.
Clinical Pharmacist: Thank you for sharing that. Let’s talk about any previous illnesses. Have you
had similar symptoms in the past or been diagnosed with any infectious diseases?
Mrs. XYZ: No, this is the first time I’ve had symptoms like this. I’ve been generally healthy.
Clinical Pharmacist: Have you recently had any vaccinations or medical treatments?
Mrs. XYZ: No recent vaccinations or treatments.
Clinical Pharmacist: Good to know. I’d like to ask about any family history of illnesses. Do any of
your family members have a history of autoimmune diseases, chronic infections, or other significant
health conditions?
Mrs. XYZ: My family has a history of autoimmune disorders, but I haven’t had any specific
diagnoses myself.
Clinical Pharmacist: That’s important information. Can you tell me if you’ve had any recent
exposure to potentially contaminated sources, such as food, water, or insects, especially if you’ve
traveled recently or live in an area with known outbreaks?
Mrs. XYZ: No recent travel, and I haven’t had any issues with food or water. I live in an area where
dengue is known to be a concern, but I haven’t had any obvious insect bites.
Clinical Pharmacist: Thanks for clarifying. I need to know about any other symptoms you might
have noticed, even if they seem unrelated, such as gastrointestinal symptoms, rashes, or changes in
urine or stool.
Mrs. XYZ: No gastrointestinal issues, rashes, or changes in urine or stool.
Clinical Pharmacist: That’s helpful. Lastly, do you have any other health concerns or symptoms that
you haven’t mentioned yet? Is there anything else you think might be relevant?
Mrs. XYZ: No, that’s everything. I just want to get better as soon as possible.
Clinical Pharmacist: Understood. Based on what you’ve shared, we’ll need to perform some tests to
determine the cause of your fever and evaluate your platelet count and other relevant parameters. In
the meantime, we can use acetaminophen to manage your fever and body pain. I’ll also advise you to
stay well-hydrated and monitor your symptoms closely.
Mrs. XYZ: Thank you for your help and advice.
Clinical Pharmacist: You’re welcome. If you have any questions or need further assistance, please
let me know. We’re here to support you.
 DEPARTMENT OF PHARMACY PRACTICE
NARGUND COLLEGE OF PHARMACY

MEDICATION CHART REVIEW FORM

Name of Participant: Mrs. XYZ
D.O.B/Age: 36 years Gender: M  F 
Diagnostic details: DENGUE FEVER WITH THROMBOCYTOPENIA
Please check all that Apply:  Medicare  Medicaid  Both  Other insurance  No
insurance
Details of Medication prescribed
Sl Medication Prescribed Dosag Strengt Freq Duratio Indication
no. e form h n
1 RINGER LACTATE) Inj 500ml SOS 3 days For fluid resuscitation
2 DEXTROSE Inj Fluid and electrolyte replenishment
ANHYDROUS+SODI 500ml SOS 3 days
UM CHLORIDE
3 PANTOPRAZOLE Inj 40mg 1-0-0 3 Days Prevent gastrointestinal bleeding
4 ONDANSETRON Inj 4mg 1-1-1 3 Days To treat nausea and vomiting
5 PARACETAMOL Inj 1g SOS 3 days Pain and fever management
1. How many medications other than the one’s prescribed is bought and consumed by the
participant currently and previously: 3
2. Did the participants get all drugs provided to them in each of their prescription medication
containers?
Yes  No 
3. Did the participant bring in all their over the counter medications and supplements?
Yes  No 
4. Has any health professional reviewed the participant's medications during the past 6 months,
Yes  No 
5. Is the participant aware of the purpose for which each of the medication was prescribed:
Yes  No 
6. Does the participant know how and when each of the medication is to be taken:
Yes  No 
7. Tick the information that you shared with the participant from the ones listed below:
How to identify expired medications by checking the label?
Importance of adhering to the medication plan or regimen
Importance of not using alternate over-the-counter medications without a prescription or without
informing the primary care provider; during the course of treatment
Availability of generics intended to reduce the medication cost.
 Other:
Please specify: __________________________________________________
Check for possible inappropriate conditions in medication regimens:
a. Duplicate medications
b. Participant taking a new prescription medication (prescribed by another doctor) without telling a
clinician.
c. Expired medications
d. Participant taking a new over-the-counter medication or supplement without telling a clinician
e. Participant had contraindication for one or more medications
f. Pill bottles brought in by participant did not match the medication list in the participant's record
g. Drug-drug interactions could be possible
h. Participant not taking medication as prescribed
i. Medication was correct, but dose was not
j. Participant failed to get medication(s) refilled
k. Participant stopped taking prescription medications without telling a clinician
l. Participant changed to cheaper medication
m. Participant stopped taking an over-the counter medication or supplement without telling a clinician.

COMMENTS:
• Ringer Lactate (Inj 500ml, SOS, 3 days):
• Monitor input and output to avoid fluid overload or dehydration.
• Regularly check blood pressure, heart rate, and respiratory rate to ensure stable
hemodynamics.
• Periodically assess electrolytes (sodium, potassium, chloride) to avoid imbalances.
• Watch for symptoms such as swelling, shortness of breath, or elevated blood pressure.
• Dextrose Anhydrous + Sodium Chloride (Inj 500ml, SOS, 3 days):
• Monitor blood glucose levels regularly, especially if dextrose is used, to prevent
hyperglycemia.
• Check electrolytes to ensure proper balance, particularly sodium and chloride.
• Track fluid intake and output to prevent fluid overload.
• Regularly monitor blood pressure and heart rate to assess the patient’s response to fluid
therapy.
• Pantoprazole (Inj 40mg, 1-0-0, 3 Days):
• Observe for any relief of symptoms such as heartburn or indigestion.
• Monitor for signs of gastrointestinal bleeding (e.g., black or tarry stools, vomiting blood).
• While not common, check renal function periodically, especially if used long-term or in
patients with pre-existing kidney issues.
• Ondansetron (Inj 4mg, 1-1-1, 3 Days):
• Evaluate the effectiveness in reducing nausea and vomiting.
• Monitor for potential side effects, such as headache, constipation, or dizziness.
• If nausea and vomiting are severe, assess electrolyte levels to ensure they remain balanced.
• Paracetamol (Inj 1g, SOS, 3 Days):
• Monitor fever to assess the effectiveness of paracetamol in reducing body temperature.
• Regularly check liver function tests (e.g., ALT, AST) if used at high doses or for extended
periods, as paracetamol can affect liver function.
• Assess for improvement in pain symptoms.
• Be vigilant for signs of overdose (e.g., nausea, abdominal pain, confusion), especially if
higher doses are used.

Reviewed by: Date:

Signature:
 PATIENT COUNSELING-08
Clinical Pharmacist: Good morning, Mrs. XYZ. How are you feeling today?
Mrs. XYZ: Good morning. I’m still feeling quite weak and a bit confused about all these medications
and what I should be doing.
Clinical Pharmacist: I understand. Let’s go over your diagnosis and the medications you’ve been
prescribed so you’ll have a clearer picture. You’ve been diagnosed with dengue fever, which is
causing symptoms like fever, body aches, and joint pain. It’s crucial to manage these symptoms and
stay hydrated. I’ll also explain about the medications you've been given. Does that sound good?
Mrs. XYZ: Yes, that sounds great.
Understanding Your Condition:
Clinical Pharmacist: Dengue fever is a viral infection spread by mosquitoes. It can cause high fever,
severe headaches, and pain in the muscles and joints. One of the concerns with dengue is low platelet
count, which can lead to bleeding problems. It’s important to stay hydrated and monitor your
symptoms closely.
Medication Counseling:
1. Sompraz D 40 Capsule SR:
Clinical Pharmacist: You’re taking Sompraz D to help with acid reflux and indigestion. This
medication works by reducing stomach acid, which should help with symptoms like heartburn and
stomach pain.
How to Take: Take this capsule without food, exactly as prescribed by your doctor. It’s important to
follow the dosage and duration instructions closely.
Common Side Effects: You might experience some diarrhea, gas, stomach pain, dryness in the
mouth, or a headache. These are usually temporary. If they become severe or persist, let me know or
consult your doctor.
Precautions: This medication can cause drowsiness or dizziness, so be careful when driving or doing
tasks that require concentration. Also, avoid alcohol because it can worsen these effects.
Lifestyle Tips: To help with acid reflux, avoid spicy foods, hot beverages like tea or coffee, and
chocolate. Drinking cold milk can soothe your stomach.
2. Dolo 650 Tablet:
Clinical Pharmacist: This tablet is used to relieve pain and reduce fever. It’s effective for headaches,
muscle aches, and other types of pain.
How to Take: Take it with food to prevent stomach upset. Follow the dosage instructions given by
your doctor. You should not take more than four doses in 24 hours, with at least a 4-hour gap between
doses.
Common Side Effects: Sometimes, it can cause stomach pain, nausea, or vomiting. If these
symptoms are bothersome or don’t go away, check in with your doctor.
Precautions: Be cautious if you have liver issues, as overuse can lead to liver damage. Avoid alcohol,
as it can increase this risk.
3. Becosules Capsule:
Clinical Pharmacist: Becosules is a multivitamin supplement. It helps with overall health by
providing essential vitamins that support your immune system, help with tissue repair, and improve
hair and skin health.
How to Take: Take it according to the label instructions. It’s best taken with food to avoid any
stomach upset.
Common Side Effects: It’s usually well tolerated, but if you have any stomach upset, taking it with
food can help.
Precautions: Store it at room temperature and keep it out of reach of children. Don’t exceed the
recommended dosage.
Lifestyle Modifications:
Clinical Pharmacist: In addition to taking your medications, here are some tips to help you feel
better:
• Hydration: Drink plenty of fluids like water and oral rehydration solutions. Avoid caffeinated
and alcoholic beverages as they can worsen dehydration.
• Diet: Stick to bland, non-spicy foods to prevent stomach discomfort. Eating smaller, more
frequent meals can also help with digestion.
• Rest: Ensure you get plenty of rest to support your recovery from dengue fever. Avoid
strenuous activities.
• Avoid Alcohol: Since you’re taking medications that can cause drowsiness, avoiding alcohol
will help prevent worsening of side effects.
Clinical Pharmacist: Do you have any questions about your medications or how to manage your
symptoms?
Mrs. XYZ: No, I think I understand better now. Thank you for explaining everything.
Clinical Pharmacist: You’re welcome! If you have any more questions or need help with anything,
don’t hesitate to reach out. We’re here to support you.