A ROLE MODEL SOAP NOTE ON MEGALOBLASTIC ANEMIA: CLINICAL PHARMACIST POINT OF VIEW Santosha Vooradi, Uday Venkat Mateti, Anantha Naik Nagappa * Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, India576104. ABSTRACT In this article, authors emphasize a case presentation on megaloblastic anemia as clinical pharmacist point of view. The need for this form of SOAP note becomes essential in managing chronic diseases and other infectious diseases. In chronic diseases conditions, the diseases are usually lifelong and with a number of comorbidities, making polypharmacy part and parcel of the overall treatment strategy. The main objective is to support patient care through the safe, evidencebased, and costbeneficial use of medicines and to maximize the clinical effects of medicines, i.e., minimizing the risk of treatmentinduced adverse events, monitoring the therapy course and the patient s compliance with therapy trying to provide the best treatment alternative for the greatest number of patient. Keywords: SOAP, Pharmacist, Hospital, Patient Care INTRODUCTION A 26 year female patient came to hospital with the chief complaints of generalized weakness for 2 months, fatigability for 2 months, fever for 4 days, and dysponea on exertion. On examination she was undernourished, pallor, icterus and splenomegaly were present. On hematological examination decreased hemoglobin (Hb), hematocrit (Hct), Vitamin B12 (Vit B12) and folic acid levels. The final diagnosis was made to be megaloblastic anemia. She was under the treatment of Tablet Paracetamol, Folic acid, Albendazole, Capsule Tramadol and Inj. Vitamin B12 1 amp. in 100 ml normal saline over ½ hour (I.V) 1. The detailed case was summarized in the Patient profile form (AppendixI). After collecting the data from the patient medical record, pharmacist makes the Subjective Objective Assessment Plan (SOAP). While subjective findings include the chief complaints of patient, objective findings include laboratory data, medical and medication history, social history, physical findings, previous allergies. Thus assessment is related to desired outcomes and end points, drug related problems and to find out whether current therapy is International Journal of Community Pharmacy, Volume 6, Number 3, September December 2013 Page 6
relevant to standard therapy or not. In planning therapeutic selection, the pharmacist has to follow monitoring parameters (therapeutic and toxicity) such as patient education, follow up and documentation of patient profile form 2. A role model SOAP note on megaloblastic anemia was discussed below. SUBJECTIVE AND OBJECTIVE EVIDENCES List of problems in this case were Vitamin B12 and Folic acid deficiency anemia. Subjective evidence in this case was generalized weakness for 2 months, fatigability for 2 months, fever for 4 days and dysponea on exertion. An objective evidence in this case was pallor, icterus, tachycardia (pulse rate 98 beats/min), moderate splenomegaly, RBC 1.9 million cell/ cu.mm (3.54.5 million cells/ cu mm),wbc1700 cells (400010,000 cells), platelets 56,000 (1,50,000 4,50,0000), Hb 5.2 g/dl (1216 g/dl), Hct 12.2 % ( 3646% ), MCV104.2 fl (83101 fl), RDW 30.2 % (1215%), Vit B12 170 pg/ml (220 1100), Folate1.8ng/ml (216), Peripheral smear shows macrocytic RBC, anisocytosis and hypersegmented neutrophils and Bone marrow shows megaloblastic maturation of precursors. ASSESSMENT Diagnosis: On the basis of subjective and objective evidences, patient was diagnosed to have Megaloblastic anemia. Etiology: female patient, Vitamin B12 and Folic acid deficiency. Assessment if therapy is indicated: Yes, therapy is must in this patient in order to prevent the further complications of anemia and to decrease the morbidity and mortality of the patient. Assessment of standard therapy: Cobalamin (1001000 µg) should be given parenterally daily for 2 weeks, then weekly until the hematocrit value is normal, and then monthly. A dose of 1000 µg is large, but it may be required in some patients. Parenteral therapy is more rapid acting than oral therapy and should be used if neurologic symptoms are present. Oral Cobalamin is initiated at 1 to 2 mg daily for 1 to 2 weeks, followed by 1 mg daily. Oral folate 1 to 3 mg daily for 4 months is usually sufficient for treatment of folatedeficiency anemia, unless the etiology cannot be corrected. If malabsorption is present, the daily dose should be increased upto 5 mg 3,4. Assessment of current therapy: Packed cell, Indication to improve oxygen carrying capacity Dose: 1pint packed cell. Tab. Paracetamol 500 mg, Indication and role fever and the role is to inhibit the prostaglandin synthesis and cyclooxygenase3 enzyme there by reducing the fever. Dose: 500mg thrice daily. Inj.Vit B12 1 amp. in 100 ml normal saline over ½ hour (I.V), International Journal of Community Pharmacy, Volume 6, Number 3, September December 2013 Page 7
Indication treatment of Vit B12 deficiency, Dose: 1 ampoule daily for 1 week, ADR s: pain at the site of injection, fever and anaphylaxis. Tab. Folvite 2.5 mg (folic acid) (100), Indication prevention and treatment of folic acid deficiency, Dose: 2.5 mg once daily. Tab. Zentel (Albendazole) 400 mg (001), Indication expulsion of worms from bowel because they compete for Vit B12, Dose: 400mg for 3 days, Adverse effects: nausea, vomiting, dizziness, headache. Cap. Tramadol 50 mg (101), Indication to relieve pain due to bone marrow aspiration, ADRs: nausea and vomiting. Final Impression by the Pharmacist: The indication, dose, dosage and duration are given according to standard therapy except Tab Albendazole. Recommended dose of Tab Albendazole for common worm infection is 400 mg as a single dose, but three doses are prescribed in special cases of Strongyloidiasis (uncommon) PLANNING General goals of therapy: To replenish body stores of Vit. B12, to bring the hematological values to normal and to prevent neurological symptoms. Patient specific goals: To treat complaints of patient and to improve working efficiency of the patient. Therapeutic monitoring: Hemoglobin, Reticulocyte count, WBC and Platelets should be monitored in this case, which are more related to disease oriented parameters. Toxicity monitoring: Liver function tests to be monitored for Paracetamol, pain at the site of injection, fever and anaphylaxis for Injection Vit.B12, which are more related to medication oriented parameters. Points to physician: In this case, Albendazole is effective as a single dose. There is no need of prescribing 3 days therapy but three doses are prescribed in special cases of Strongyloidiasis (uncommon). PATIENT EDUCATION About Disease: You are suffering from disease called megaloblastic anemia due to deficiency of Vit B12 and folate, in which there is decreased hemoglobin level, due to which oxygen supply to tissues is less. About Drugs: Here, pharmacist has to discuss about the importance of using medication (medication adherence), role of the drugs in the therapy, when to take the medication like before or after food and most common side effects. International Journal of Community Pharmacy, Volume 6, Number 3, September December 2013 Page 8
Lifestyle modification: Patients should have dietary rich in folic acid. Examples of such foods include asparagus, broccoli, spinach, lettuce, lemons, bananas, melons, liver, and mushrooms. To prevent loss of folate, foods should not be cooked excessively and should not be diluted in large amounts of water. To prevent Cobalamin deficiency, vegetarians should include dairy products and eggs in their meals. Patients should know that goat milk contains less amount of folate 4. Follow up: Patient was discharged with Inj.Vit.B12 I.M weekly for 4 weeks, Tab. Folvite 2.5mg 100 for 4 weeks and review after 1 month in medicine outpatient department with Complete blood count (CBC) report. REFERENCES 1. Ladd EM, Inech JT, Mason BJ. Haematological disorders. In: Terry LS, Koehler JM, editors. Pharmacotherapy casebook. New York: McGrawHill; 2010. 263265. 2. Uday VM, Rajesh V, Avinash L, Shreekant S, Anantha NN. Activities of Pharma D students in south Indian hospital. The Pharma Review. 2011 MarApr; 7(2):133135. 3. Dipiro CV. Haematological disorders. In: Wells BG, Dipiro JT, Terry LS, Dipiro CV, editor. Pharmacotherapy Handbook. New York: McGrawHill; 2010. 36570. 4. Paul S, Thomas HD, Francisco T, Ronald AS. Megaloblastic Anemia Treatment & Management. Available URL: http://emedicine.medscape.com/article/204066 treatment#aw2aab6b6b2. [Last cited on Nov 10, 2013]. International Journal of Community Pharmacy, Volume 6, Number 3, September December 2013 Page 9
APPENDIXI Patient Profile Form AGE: 26 years WEIGHT: 42Kg SEX: Female DATE OF ADMISSION: 22/03/11 DATE OF DISCHARGE:30/03/11 COMPLAINTS ON ADMISSION: generalized weakness x 2 months, fatigability x 2 months, Fever x 4 days, Dysponea on exertion. MEDICAL HISTORY: Nil, MEDICATION HISTORY: Nil, SOCIAL HISTORY: Not a smoker and alcoholic FAMILY HISTORY: Married, PREVIOUS ALLERGIES: Nil PHYSICAL EXAMINATION: Undernourished GENERAL Pallor + / icterus + /Cyanosis /Clubbing /Edema VITAL SIGNS Blood Pressure (BP). 110/78 mm Hg, Pulse Rate(PR). 98 beats/min., Temperature 100F HEENT Normal, Cardiovascular System S 1,S 2 +ve, Respiratory System Normal, Gastrointestinal Track Splenomegaly +ve, Central Nervous System Not Appreciable Diagnosis PROVISIONAL DIAGNOSIS: Malaria or Anemia.? ROUTINE BIOCHEMICAL INVESTIGATIONS Urea: 25 mg/dl, Serum Creatitin : 0.8 mg/dl, Sodium: 131meq/lit, Potassium: 3.8meq/lit, Total Bilirubin: 0.2 mg/dl, Direct Bilirubin: 0.4 mg/dl, Total Protein: 5.9g/dl Albumin: 4 gm/dl, Globulin: 1.9gm/dl, Aspartate transaminase: 27 IU/L, Alanine aminotransferase: 16 IU/L, Alanine Lysine Protein: 31 IU/L HAEMATOLOGY: Red Blood Cells(RBC) : 1.9 million cells/cu.cm, Retics: 1.3%, White Blood Cells(WBC): 1700 cells, Neutrophils: 38.1%, Leukocytes: 50.2%, Monocytes: 8.5%, Eosinophils: 2.9%, Basophils: 0.3%, Hemoglobin(Hb): 5.4 g/dl, Hematocrit(Hct): 12.2 %, Mean Cell Volume(MCV) :104.2 fl, Mean Cell Hemoglobin(MCH):34pg, Erythrocyte Sedimentation Rate(ESR): 60 mm/hr, Platelet: 56,000 URINE ANALYSIS ph: WBC: 01 cells Protein: trace RBC: 01 cells Sugars: ++ Epithelial Cells: Nil Blood: Casts: Nil Crystals: Nil OTHERS Quantitative Buffy Coat ve, Coomb s test ve, Ferrous 106 ug/dl, Total Iron Bininding Capacity 221 ug/dl, Red cell distribution width 30.2%, Vit.B12 170pg/ml, Folate 1.8ng/ml, Peripheral smear: Macrocytic, anisocytosis, hypersegmented neutrophils, polychromasia, Bone marrow : Megaloblast maturation of precursors Final Diagnosis: Megaloblastic anemia International Journal of Community Pharmacy, Volume 6, Number 3, September December 2013 Page 10
DRUG TREATMENT CHART: GENERIC NAME Paracetamol Tramadol (opioid analgesic) Vit.B12 Folic acid Albendazole DRUG WITH DOSE & ROUTE BRAND NAME Tab. Calpol 500mg (111) Packed cell transfusion 1 pint Cap. Tramazac 50 mg (101) Inj. Eldervit 12 1 amp. in 100 ml normal saline over ½ hour (i.v) Tab. Folvite 2.5 mg ( 100) Tab. Zentel 400mg (001) 1 2 3 4 5 6 7 8 9 PROGRESS CHART: DAY 22/01/10 23/01/10 24/01/10 25/01/10 26/01/10 27/01/10 INVESTIGATIONS Fatigability, pallor, B.P 110/78, PR 98/min Hb 5.4 Afebrile, pallor +, PR83/min, B.P140/90 Bone marrow study Fatigability, afebrile, PR86/min,B.P 110/70, Bone marrow done Better, no fresh complaints, bone marrow awaited, Hb 6.2 g/dl, WBC 2500, Platelet 63,000 Better, afebrile, No fresh complaints No fresh complaints, better, Hb 6.4 ESR37 mm/hr, 28/01/10 29/01/10 No fresh complaints Better, no generalized weakness, PR 71/min, B.P 120/78 mm Hg DISCHARGE MEDICATIONS: Inj. Eldervit. 12 Tab. Folvite 1 amp i.m once weekly x 4 weeks 2.5 mg 100 x 4 weeks 30/01/10 No fresh complaints, feeling better, afebrile,pr80beats/min, HB 6.8 g/dl, WBC 3500, Platelet184000, ESR 9 mm/hr FOLLOW UP/REVIEW: Review After 1 Month In Med. I OPD With Complete Blood Count(CBC) Report International Journal of Community Pharmacy, Volume 6, Number 3, September December 2013 Page 11