9. 案例報告的組成
• General information
• Chief complaint (CC)
• History of present illness
(HPI)
• Past medical history
(PMH)
Medication history
(MedHx)
• Family history (FH)
• Social history (SH)
• Review of systems (ROS)
• Physical examination (PE)
• Pertinent positive and
negative laboratory and
diagnostic test results
(Labs)
• P’t problem list and initial
plans
• P’t progress
• Discharge data
▫ Final diagnosis
▫ Discharge medications
• Plans for follow-up
9
29. 舉例 TDM
105-2-7
Problem: Bacteremia with ORSA infection
SO: B/C yeilded ORSA, WBC 18,000/uL, N.seg 80%, Scr 4.5
mg/dL, BUN 47 mg/dL, Vancomycin trough level 25 mg/dL
Vancomycin dose 1g qd IVD
A: TDM of vancomycin and trough level is too high
P: Please adjust vancomycin dose to 1g qod IVD and check its
trough level on 2/15 and keep following infection sign
(CBC/DC, fever) and renal function (Scr/BUN, I/O).
Thank you a lot
藥字第 xxxx
號
李 xx 藥師
Pharmacist Note
記得寫上時間與
Pharmacist Note 的章
主要的醫療問題 , 別忘
了一個問題一個 SOAP
若病人昏迷 , SO 可以寫在一起，建
議可寫和本次藥物問題相關的資料
A: 要記住別抄醫師的診斷應寫藥師
評估的藥物治療問題
P: 要清楚描述藥物修改的劑量與監
測的時間
30. 舉例 TDM ( 簡易板 )
105-2-7
Please adjust vancomycin dose to 1g qod IVD and check its
trough level on 2/15 and keep following infection sign
(CBC/DC, fever) and renal function (Scr/BUN, I/O).
Thank you a lot 藥字第 xxxx
號
李 xx 藥師
Pharmacist Note
31. 舉例 DDI
104-6-20
Problem: CHF
SO: Cardiac echo showed LV systolic function (EF: 42%)
Scr 5.8 mg/dL, BUN 137 mg/dL, Na 139 mmol/L, K 2.5
mmol/L
Spironolactone 1# bid po for CHF, slow-K 1# tid po for
hypokalemia
A: DDI of spironolactone and slow-K
P: Please keep following vital sign and renal function (Scr/BUN,
I/O). and electrolyte (K level on 6/22)
If K level get back to normal or too high, please DC slow-K.
Thank you a lot 藥字第 xxxx
號
李 xx 藥師
Pharmacist Note
32. 舉例 DDI ( 簡易板 )
104-6-20
Please keep following vital sign and renal function (Scr/BUN,
I/O). and electrolyte (K level on 6/22)
If K level get back to normal or too high, please DC slow-K.
Thank you a lot 藥字第 xxxx
號
李 xx 藥師
Pharmacist Note
33. 舉例 ADR
104-10-2
Problem: General erythematous skin rash, suspected drug
related?
SO: Skin rash showed 7 days after adding phenytoin and other
concurrent medications were used before. Skin rash
improved after DC phenytoin.
A: Suscpected phenytoin induced general erythematous skin
rash
P: Please DC phenytoin ST and give her steroid and
antihistamine according to Dermatologist suggestion. Please
record her allergic history of phenytoin.
Thank you a lot 藥字第 xxxx
號
李 xx 藥師
Pharmacist Note
34. 舉例 ADR ( 簡易板 )
104-10-2
Please DC phenytoin ST and give her steroid and antihistamine
according to Dermatologist suggestion. Please record her
allergic history of phenytoin.
Thank you a lot 藥字第 xxxx
號
李 xx 藥師
Pharmacist Note
35. 舉例 : 若無藥物相關問題
105-01-2
No drug related problems
Please keep current medication use
Thank you a lot 藥字第 xxxx
號
李 xx 藥師
Pharmacist Note
38. 教學大綱
• 課程目標
• 病歷之基本組成
▫ Patient Case Presentation
• From database to plan
▫ 1. From data base to assessment (SOAP notes)
▫ 2. Assessment
▫ 3. From assessment to plan (Implentation)
• SOAPing format
▫ 案例說明
Daily SOAP note
Oral case presentation
38
