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Wednesday, September 11, 2019

SOAP Note Essay Example | Topics and Well Written Essays - 750 words

SOAP Note - Essay Example As a pharmacist, I have employed SOAP note format on various occasions, one of which involved a 62 year old woman. She came to the CVS clinic complaining of constipation and inquired on the availability of any drug that could assist in countering the condition. After careful assessment, I recommended her Senokot tablet. I did this after following SOAP note format for collecting information about the patient. The first questions I asked the patient were subjective and aimed at knowing how the patient felt. They aimed at knowing the symptoms of the condition the patient had. Constipation was the main problem the woman had. However, it was accompanied with abdominal pain and regular movement of the bowel (Ferrell, Betty & Nessa 516). She informed me that the first time she experienced the problem was two weeks ago and that it has occurred daily since then. After constipation, she usually looses appetite for several hours. I carried out an objective observation of the patient and this started by first asking the patient other conditions that she suffers from. I sought to know if she had heart disease or bowel disorder such as Crohn’s disease. She did not have any other disease or condition and was not under any other medication. However, her abdomen was swollen and there were infrequent actions of the bowel. Subsequently, I carried out an assessment of the patient and directed that some tests to be done to properly diagnose the condition. I found that she had hard stools and felt nausea and vomited at times. The tests I ordered to be carried out were blood tests, barium tests and colonoscopy. These were to determine weather the cause was hormonal imbalance or colon obstruction respectively. . The patient complained of abdominal pain and regular abdominal movements. She also felt tired and dizzy even without doing any physical work. She also complained of

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