this is a very good and convient presentation for elaboration of details which you collect at the ward round

1. By: - Ravi Kumar
Class: - Pharm D
Year: - 2nd Year
SOAP Note Of Case
Collected During
Ward Round

2. THE PATIENT IS
OBSERVED
HIV POSITIVE

3. HISTORY SECTION

4. SYMPTOMS (usually observed)
 Nausea
 Vomiting
 Persistent diarrhoea
 Chronic fatigue
 Rapid weight loss
 Cough and shortness of breath
 Recurring fever, chills, and night sweats
 Rashes, sores, or lesions in the mouth or nose, on the
genitals, or under the skin
 Prolonged swelling of the lymph nodes in the armpits,
groin, or neck
 Memory loss, confusion, or neurological disorders

5. SYMPTOMS (observed in patient)
 Fever (1040 F) relives only after taking medicines
(2 Days)
 Vomiting (1 Day)
 Uprolling of eyes
 Body Rashes (Past Few Days)
 Sore Throat (5-6 Days)
 Sever Headache (5-6 Days)

6. Information From Other Source
 It can spread through sexual contact or blood
 By having sex
 From blood transfusions
 By sharing needles
 During pregnancy or delivery or through breast-
feeding

7. PAST MEDICAL HISTORY
 Chronic Alcoholic
 Non Smoker
 Mixed Vegetarian
 No H/O Drug Addiction
 No H/O TB/HPT/BA/Blood Transfusion
 No Such Allergy

8. PERTINENT REVIEW OF SYSTEMS
 No joint pain is observed
 No Muscle Stiffness Is Observed
 No Body Pain Is Observed
 No Loss of motion of other joints

9. CURRENT MEDICATIONS
S.No MEDICATIONS Dose Route Frequency
1. Inj Gramocef 1 g IV BD
2. Inj Vancomycin 1 g IV BD
3. Inj Dexamethasone 2 cc IV BD
4. Inj Mannitol 100 ml IV TDS
5. Inj Pantop 40 mg IV OD
6. Inj Gramocef 2 g IV BD
7. Inj Vancomycin 1 g IV BD
8. Inj Dexa 4 cc IV TDS
9. Inj PMOL 4 cc IV TDS
10. Inj Teicoplanin 400 mg IV BD
11. Inj Ampicillin 2 g IV Q 4H
12. Inj Teicoplainin 200 mg IV OD

10. OBJECTIVE

11. PHYSICAL EXAMINATION
 Temperature – To check body temperature normal or not
 Weight – Check the sudden weight loss or gain
 Eye –Cytomegalovirus (CMV) retinitis is a common
complication of AIDS
 Mouth – to check Oral yeast infections

12.  Lymph node –to check Lymph node enlargement
(lymphadenopathy)
 Abdomen- The abdominal exam may show an
enlarged liver
 Skin- Skin problems are common for people with HIV
infection seborrheic dermatitis to Kaposi's sarcoma.
 Gynaecologic - Women who are HIV-infected have
more cervical cell abnormalities than women who do
not have HIV.

13. LABORATORY TESTS
S.No Name of Test Values observed Normal values
1. CSF Cholesterol 126 mg/100ml 406 mg/100 ml.
2. CSF Glucose 23 mg/dl 45–80 mg/dL
3. CSF Protein 37.8 gm 45–80 mg/dL
4. Calcium serum 7.0 mg/dl 8.5-10.2 mg/dL
5. CBC(complete blood count) 65 gram/L 135-175 grams/L
6. Electrolyte 150 mEq/L 134 to 145 mEq/L
7. HBsAg Card Test 15 mIU/ml >12 mIU/ml
8. HIV Antibiotic 1&2 test 100% -----------------
9. LFT 265 U/L 45 to 115 U/L
10. Protein total – TSP 55 g/L 35-50 g/L

14. MICROBIOLOGY TEST
Gram stained smear shows no
polymorphonuclear cells, no
gram positive organism or gram
negative organism seen

15. ASSESSMENT

16. Detail of Patient
 Name: - Jasa Singh
 IP/Reg No.- 20428
 Sex: - Male
 Tel No: - 9356620833
 Ward No.: - Medicine Ward II
 Date of Admission: - 24th July 2018
 Weight: - 69 kg

17. Major Problems Faced
S.No List of Problems Detected or not
1. Fever Detected
2. Vomiting Detected
3. Rashes on Skin Detected
4. Sore Throat Detected
5. Sever Headache Detected
6. Blood in stool Not Detected
7. Cough and Shortness of Breath Not Detected
8. Memory Loss Not Detected

18. Plan

19. Tests Required
1. Antibody Screening Tests
These tests check for a kind of protein that your body makes in
response to the HIV infection, 2-8 weeks later. They're also
called immunoassay or ELISA tests.
2. RNA Test
This looks for the virus itself and can diagnose HIV about 10
days after you've been exposed
3. NATs
NATs look for HIV in the blood. NATs can detect HIV infection
about 7 to 28 days after a person has been infected with HIV.

20. Medication Required
 HIV required Nucleoside/nucleotide reverse transcriptase
inhibitors (NRTIs) types of medicine:-
 Abacavir (ziagen)
 Abacavir/lamivudine (epzicom)
 Abacavir/lamivudine/zidovudine (trizivir)
 Lamivudine/zidovudine (combivir)
 Lamivudine (epivir)
 Zidovudine (retrovir)
 Emtricitabine/tenofovir disoproxil fumarate (truvada)
 Emtricitabine (emtriva)