药事执业技能药物相关问题之解决pharmacypracticeskillsdrug.pptVIP

其他注意事項 雖然有主題報告，仍有學員不熟悉SOAP，有時需解釋並分辨哪些屬於S、哪些屬於O、哪些屬於A、哪些屬於P，請在課程報告中詳述佐以實例說明。 學員大部分都很怕講錯，一定要讓學員了解，課程是要訓練他們熟悉寫SOAP的思考模式和流程，所以上課時不要太在意所提出的PLAN對不對，而輔導員或主持人在講評時也儘量針對SOAP本身就好（除非真的建議的內容太離譜啦~）。 雖然練習的個案資料內容很豐富，但是要提醒學員在實際臨床時，有些資料不是光靠病歷閱讀來取得，尤其是針對藥物的部分（過去用藥史，有病史為何未用藥？...等等）。 善用手冊的SOAP表單，更能掌控A、P呈現的重點。 * Family History (FH)家族病史 Mother died of an MI at age 68. Father died of lung cancer at age 75. * Medication Record (Prescription and OTC) (MedHx)用藥史 Furosemide 40 mg po q AM Albuterol inhaler 2 puffs qid prn Beclomethasone inhaler 1 puff qid Ibuprofen 800 mg po tid Herbal product with licorice po qd Acetaminophen po prn * Review of Systems (ROS)現有疾病或問題 (HPI 除外) Wheezing and coughing * Physical Examination (PE)身體診察 VS: BP 160/100 mmHg HR 120 beats/min RR 31 rpm T 38.5℃ Ht 175 cm BW 95.4 kg BMI 31.2 (95.4/1.75x1.75) CHEST: Expiratory wheezes * Laboratory and Diagnostic Tests (Labs)檢驗數據及檢查報告 Potassium 3.8 mEq/L Sodium 145 mEq/L Serum creatinine 1 mg/dL FBG 100 mg/dL Total cholesterol 200 mg/dL HDL 35 mg/dL RBC 4.7 cells/mm3 Hgb 15 g/dL Hct 44% PH 7.40 PaO2 55 mmHg PaCO2 40 mmHg * Diagnosis診斷 Primary: 1)Asthma 2)Hypertension Secondary: 1)Benign prostatic hyperplasia 2)Rheumatoid arthritis Problem list * Problem List Current medical problems Goal of therapy Measurable endpoint Primary: 1)Asthma Symptom control Prevent asthma episodes or attacks PEFR No DOE, SOB, PND 2)Hypertension Prevent CHD, Stroke and Nephropathy BP Secondary: 1)BPH Symptom control DRE (digital rectal exam) UFR (urine flow rate) 2)RA Improve QOL Arrest or retard disease progress Swollen tender joints RF, ESR, ANA, CBC X-Ray * Current Drug-Therapy Problems Subjective and Objective Problem(subjective and objective) Current medication S: Pertinent medical Hx:Asthma x 20 yrs; RA x 5 yrs; BPH x 1yr ago; HTN x 5wks ROS: respiratory distress with severe dyspnea ; wheezing and coughing Tobacco use: 0.5 pack/week ; alcohol use: 6 pack / week ; caffeine use: 2 cups of coffee every morning Use a