Description
You sould write a soap note for the dirrhea case that I uploaded based on my refrence and guid that I uploaded. Please do not use the word out of my reference file and follow the guide carefully. for writing the soap note just use Diarrhea file information that I uploded and you have 2 guide Written communication power point and soap note template.
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OTC Case Write-up 2
Jane Smith is a 36-year-old female arriving to your pharmacy complaining of diarrhea. She
reports, “I have been having watery stools for the last 2 days. I am not sure what it could be!”
She reports frequent episodes of loose watery stools (3-4 loose stools/day) and denies nausea,
blood, or mucus. She states she has had chills, vomiting, and a headache, which has caused her
to stay in the bed for the last 24 hours. She reports that the symptoms started about 4 hours
following dinner at a new restaurant downtown. The episodes usually occur all day preventing
her from going into the office for work. She states she has tried to eat chicken noodle soup with
ginger ale but cannot seem to keep any food down. She states that nothing seems to be making
it better. She reports drinking lots of Gatorade to remain hydrated but states this seems to
make her symptoms worse. She asked her doctor what she should do and he said to wait it out
and see the pharmacist for something over the counter as it is not severe enough. She denies
abdominal pain, pregnancy, and any recent travel outside of the U.S. She reports a past medical
history of HTN controlled by lifestyle modifications. When asked about her weight she claims it
may have changed a few pounds from 156lbs to 149lbs. She is taking St. John’s Wort for
depression per her doctor. She is allergic to latex (hives) and aspirin (anaphylaxis). You note
that the patient is perspiring and looks distressed.
Patient initials, date, location (if applicable)
SOAP Note Template with supplemental comments; skeleton template on next page
Do NOT submit a SOAP note with these supplemental comments/prompts
S:
CC: [Chief Complaint: May be a quote from the patient (usually about a symptom or new
problem) or simply the reason for the visit. Only include information pertinent to the visit.]
HPI: [History of Present Illness: A narrative related to the CC, the purpose of which is to provide
background information pertinent to the visit. Only include information pertinent to the visit.]
FH: [Family History: Medical information for blood relatives; may write in list or sentence form;
only include information pertinent to the visit; if unknown or noncontributory, state as such.]
SH: [Social History: May include occupation, living situation, level of education, exercise status,
use of alcohol/tobacco/illicit drugs. Diet may also be included here or described as part of HPI. If
diet is explained sufficiently in HPI, could simply state, “Diet as per HPI” in the SH section. May
write in list or sentence form; only include information pertinent to the visit; if unknown or
noncontributory, state as such.]
ROS: [Review of Systems: Subjective patient-reported symptoms; may write in list or sentence
form; only include information pertinent to the visit; if unknown or noncontributory, state as
such.]
PMH: [Past Medical History: A list of medical problems/diagnoses with duration or dates of
diagnosis if known. You may write this in sentence form if you desire, but simply a list is
sufficient. Only include information pertinent to the visit.]
Meds: [Medications: List ALL medications. Include full sig of drug, dose, route, frequency,
duration (if not chronic).]
Immunizations: [List ALL immunization with dates if known.]
ALL: [Allergies: List ALL allergies. Include offending agent and reaction (if known) in
parentheses. Note if it is an intolerance.]
O:
VS: [Vital Signs: Generally, includes height and weight, often written as: BP x, P x, RR x, T x, Ht
x, Wt x, BMI x. Include units for Ht & Wt. Include the most recent value of each, including the
date. If any are not known, delete the individual prompt; however, do calculate and include BMI
if Ht and Wt are available.]
PE: [Physical Examination: Only include information pertinent to the visit.]
Labs: [Include actual lab values with units; do NOT state “WNL.” Always include calculated CrCl
(with or without eGFR) if SCr is available. Include dates of labs if different from your encounter
date. Only include information pertinent to the visit.]
Diagnostic tests: [Only include information pertinent to the visit. If not needed, may delete the
“Diagnostic tests” prompt. (This ONLY applies to the “Diagnostic tests” prompt; all other
prompts/sections should remain in the note.)]
A: [Assessment should justify the plan! Put the pt’s identified problems in a prioritized list (from
most acute/important to least pressing). Include goals of therapy, pertinent +/-, considerations
for therapy. Cite guidelines & primary literature as appropriate.]
1. [Problem 1 with goals of therapy, assessment of the problem and current treatment, and
justification/rationale for continuation of or changes to treatment with appropriate
references]
2. [Problem 2 with goals of therapy, assessment of the problem and current treatment, and
justification/rationale for continuation of or changes to treatment with appropriate
references]
P: [Plan should include specific, clear, easy-to-follow action items. Plan should be in same order
as A, but not necessary one-for-one (i.e., may have multiple action items for one problem; could
[Name], PharmD Candidate, Class of ____
Patient initials, date, location (if applicable)
put follow-up as last in list even though it may relate to multiple problems). Include
pharmacological (full sig/order) and non-pharmacological interventions, counseling/education,
monitoring, follow-up.]
1. [Problem 1 with treatment plan, safety/efficacy counseling, non-pharmacological
interventions, and safety and efficacy monitoring]
2. Problem 2 with treatment plan, safety/efficacy counseling, non-pharmacological
interventions, and safety and efficacy monitoring]
• Preventative Health: [Include any recommendations for immunizations, routine health
screenings, and/or lifestyle changes]
• Follow-up/Referral: [State when patient should follow up with provider and any specific
actions that need to be taken at that follow up, make referrals to any additional providers
that may be out of the scope of the pharmacist at this visit]
Formatting instructions:
Format: Header includes patient initials, date, and location. Footer includes student name
and credentials. Submits as a word document with a length that does not exceed 2 singlespaced pages utilizing 11-point Arial font and 1-inch margins.
Readability: Utilizes appropriate medical language, grammar, spelling, and abbreviations
(see lists from ISMP and Joint Commission for do not use abbreviation lists) throughout the
note. Written so that it can easily be read and understood by a medical provider.
• Full credit if no errors and easily read without having to re-read for understanding
message.
• Half credit if 1 error or requires 1 re-read to understand message.
• No credit if 2 or more errors or requires 2 or more re-reads to understand message.
[Name], PharmD Candidate, Class of ____
Patient initials, date, location (if applicable)
S:
CC:
HPI:
FH:
SH:
ROS:
PMH:
Meds:
Immunizations:
ALL:
O:
VS:
PE:
Labs:
Diagnostic tests: (may delete this prompt if no diagnostic tests are available or they are not
pertinent to your encounter)
A:
1.
2.
P:
1. Problem 1: Treatment Plan
Counseling:
Nonpharm:
Monitoring:
2. Problem 2: Treatment Plan:
Counseling:
Nonpharm:
Monitoring:
• Preventative Health:
• Follow-up/Referral:
[Name], PharmD Candidate, Class of ____
Sarah M Anderson, PharmD
PCS 7310 Ambulatory Care Skills I
2024
▪ Mospan. Diarrhea. Handbook of Nonprescription Drugs Quick Reference. 2nd
edition. 2021.
▪ Walker PC, Dang RH. Chapter 16: Diarrhea. Handbook of Nonprescription Drugs:
An Interactive Approach to Self-Care, 20th Edition.
▪ Distinguish severity of diarrhea
▪ Understand self-care treatments for diarrhea
▪ Evaluate and select appropriate OTC and nonpharmacologic care options for
patients
1. Prevent or correct fluid and electrolyte loss
2. Control symptoms
3. Identify and treat cause
4. Prevent acute morbidity and mortality
▪ Acute diarrhea
▪ Symptoms< 14 days
▪ Generally managed with fluid and electrolyte replacement, dietary interventions, and
nonprescription drug treatment
▪ Increase in stool frequency (>3 bowel movements/day), liquidity of stool, or weight
▪ Persistent diarrhea
▪ Symptoms lasting 14-28 days
▪ Often secondary to chronic medical conditions or treatments
▪ Chronic diarrhea
▪ >28days
▪ Often secondary to chronic medical conditions or treatments
**Diarrhea can be accompanied by generalized symptoms such as N/V, HA, Fever, myalgia**
Virus
Population
Route
Symptoms
Treatment
Prognosis
Rotavirus
Onset 24-48h
acute watery
diarrhea
5-8 days
Norovirus
Onset 24-48h
SUDDEN
watery
diarrhea
12-60 hours
Traveler’s diarrhea possible organisms
Bacteria
Symptoms
Treatment
Campylobacter
jejuni
Onset 24-72h
watery diarrhea
E. Coli
Onset 8-72h
watery diarrhea
Abdominal
cramps, bloating
Severe,
persistent, or
complicated
cases refer for
additional
assessment and
treatment
Salmonella
C. Difficile
Route
Prognosis
>7d
3-5d
Onset 12-24h
Diarrhea,
epigastric pain,
anorexia
~24 hours
Watery or
mucoid diarrhea,
high fever,
cramping
Recurs
Protozoa
Route
Giardia
intestinalis
Water
contaminated
with feces
Traveler’s diarrhea possible organism
Symptoms
Onset 1-3w
Watery or
mucoid diarrhea,
gas, abdominal
bloating,
epigastric pain
Treatment
Prognosis
Refer for
antimicrobial
therapy
Resolves with
treatment
▪ Lactose intolerance
▪ Body is unable to fully digest sugar (lactose) in milk
▪ Results in bloating, gas, and diarrhea
▪ Lactase enzyme is in the brush border of the small
intestine → those who lack this enzyme cannot absorb
lactose → osmotic diarrhea
▪ Antibiotics
▪ Colchicine
▪ Metformin
▪ Magnesium
▪ Orlistat
▪ Osmotic laxatives
▪ GLP-1
▪ SSRIs
▪ Osmotic: Altered absorption in the intestines
causing decreased fluid absorption
▪ Secretory: Crypt cells produce flow of
electrolytes and fluid into the lumen
▪ Inflammatory: Impaired fluid absorption and
leaking of mucus, blood and pus into lumen due
to inflammation of intestinal mucosa or bacterial
infection
▪ Motor: Abnormally rapid intestinal transit time
SEVERE
DEHYDRATION
▪ Alice Kim is a 27-year-old female presenting with intermittent
diarrhea that has occurred for the past 3 years. She often has
abdominal cramping with watery diarrhea and lots of gas
several times per week. Denies vomiting, fever, blood in stool,
weight loss, or other signs and symptoms. She has not traveled
internationally recently. She eats a balanced diet, but likes
dessert (especially ice cream), and drinks wine and beer
several times a week. She states she sleeps 8 hours a night.
▪ What is relevant to her clinical presentation?
▪ What do you think the cause of her diarrhea to be?
▪ Age
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