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Subjective Objective Assessment Plan Patient Education: Case No.: Date
Subjective Objective Assessment Plan Patient Education: Case No.: Date
Subjective Objective Assessment Plan Patient Education: Case No.: Date
:
Date:
SUBJECTIVE
PROBLEM
OBJECTIVE
1.VITAL SIGNS
2.LAB TESTS
3.MED.LIST
ASSESSMENT
ETIOLOGY OF
PROBLEM
1.EVALUATE
CURRENT
THERAPY FOR
PROBLEM
PLAN
GOALS FOR
TREATMENT
OF PROBLEM
RECOMMEND
1. DRUG TREATMENT FOR
PROBLEM
2. MONITORING PARAMETERS
FOR EACH DRUG LISTED
3. FURTHER TESTS FOR PROBLEM
IF NEEDED
4. DRUGS TO BE AVOIDED AND
WHY
2.EVALUATE NEED
FOR THERAPY
JAUNDICE
60 yrs male, was
Vitals:
Jaundice is caused by a
1. Current
To reduce the
P.R :86/min
build-up of bilirubin in
treatment with
Total bilirubin
Pantoprazole-40mg
to consume plenty
following drugs
levels
Paracetmol-500mg
of fluids and
B.P :130/80 mm of Hg
admitted on 24/08/2014
RR : 26 / min
provides quick
with c/o
recovery of patient
To reduce the
* Fever, Yellowish
Labs:
from jaundice.
fever &
as cirrhosis, hepatitis or
a) Urso deoxy
DAY
Hemoglobin
ESR
RBC
Total count
Serum Creatinine
Total Protein
SGOT
SGPT
ALP
Bilirubin total
1
10.39 g/dl
23mm/hr
1.5 m/dl
13700/cum
3.5g/dl
6.4mg/dl
69u/l
80u/l
30.7mu/ml
3.2mg/dl
Current medication:
PATIENT
EDUCATION
gallstones.
Certain individuals with
hereditary conditions
(for example,
thalassemia or
hereditary
spherocytosis) are at an
increased risk of
developing jaundice
abdominal pain
cholic acid -
vegetables and
repeated.
Naturally Occurring
To stop the
help treat
vomiting
jaundice.
reduction of
Jaundice.
b) Paracetamol
alternatives.
antipyretic to
c) Pantoprazole
Proton pump
inhibitor as the
Individuals who
patient c/o
abdominal pain.
from hemolysis.
following a diet
hepatitis, pancreatitis,
No change to
Department of Pharmacy Practice, Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor-517127 (AP), INDIA
Case No.:
Date:
and cirrhosis leading to
current therapy is
required except
patient is alcoholic
Baclofen (Anti
cholestatic jaundice.
Spastic)
Key Points
Suspect acute viral hepatitis in patients, particularly young and healthy patients, who have acute jaundice, particularly with a viral prodrome.
Suspect biliary obstruction due to cancer in elderly patients with painless jaundice, weight loss, an abdominal mass, and minimal pruritus.
Suspect hepatocellular dysfunction if aminotransferase levels are > 500 U/L and alkaline phosphatase elevation is < 3 times normal.
Suspect cholestasis if aminotransferase levels are < 200 U/L and alkaline phosphatase elevation is > 3 times normal.
Department of Pharmacy Practice, Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor-517127 (AP), INDIA