SOAPE Note and Pharmaceutical Care Plan: DG Case, PHA6636, Fall 2024

This assignment presents a SOAPE (Subjective, Objective, Assessment, Plan, Education) note for a 58-year-old male, DG, with alcoholic liver disease, cirrhosis, and a history of spontaneous bacterial peritonitis (SBP). The note details the patient's current medications, vital signs, and lab results. The assessment identifies constipation and potential encephalopathy as concerns. The plan includes discontinuing antibiotics, continuing other medications, and initiating a laxative (Bisacodyl) for constipation management. Education is provided to the patient and his wife regarding the condition, medications, and lifestyle modifications, including a high-fiber diet. The document emphasizes the importance of monitoring for side effects and the need for patient involvement in their treatment. References are included for supporting evidence.

SOAPE
Student’s name:
Institutional:

Subjective
DG is a 58-year old male who is visiting his PCP for follow -up after having been discharged
from hospital for the treatment of spontaneous bacterial peritonitis (SBP). He has alcoholic liver
disease.
PMH: Alcoholic liver disease with cirrhosis and ascites, encephalopathy, portal hypertension and
osteoarthritis in both knees.
FH: Has no contribution
SH: He denies having used illicit drugs. He also quit smoking 20 years ago and have not taken
alcohol for 6 months.
HEENT: Has no icterus. Nystagmus PEERLA, EOMI present.
Medications
Cipro 500mg PO BID completed a 7-day course
Propranolol 20 mg PO BID
Spironolactone 50 mg PO daily
Furosemide 20 mg PO daily
Objective
Vital signs: BP 120/70 mmHg, HR 72, RR 16, T 99F
Wt 100kg ht 5’10”
Lung CTA
Heart RRR no m/r/g Abd + ASCITES
No evidence of Jaundice or edema Asterixis present
He also had a shuffling walk and trouble remembering three words.
Na – 138mEq/L, K- 3.8mEq/L, Cl- 99 mEq/L, BUN- 10 mm/dL WBC – 5.6 x 103/mm3

AST- 55 U/L, ALT- 35 U/L, TSH 3.2 mU/L
Assessment
DG has finished his antibiotics for SBP and is complaining of constipation. He also complains of
fullness in his stomach. The wife also raised her concerns that he might be getting loopy again.
Plan
Review DG’s current medication and ask for any side effects experienced.
Discontinue Cipro because the patient has completed the 7-day course
Continue Propranolol because it is a beta-blocker to manage high blood pressure (Ambrozini et
al. 2016)
Continue Spironolactone and Furosemide. These are diuretics
Commence a laxative to manage his constipation problem.
Problem Desired outcome Proposed therapy and
duration
Monitoring Parameters
Constipatio
n
The patient to be relieved
from the discomfort of
constipation.
Laxative: Bisacodyl
10mg PO OD for 7
days
Also, advise the
patient to consider
taking meals with
fiber.
Monitor the frequency of
stool passage. Monitor for
abdominal cramping,
electrolyte imbalance and
excessive diarrhea.
Education
Educate the patient more about his condition and the like hood causes of the problems he is
experiencing. Moreover, I will explain all the details concerning the medications prescribed to

the client (Nieuwlaat et al. 2014). This includes; the name of the drug, dosage, uses and the side
effects. Patient education is an essential aspect since the patient gets involved in his treatment.
The wife will also be educated concerning the same since she is the one who takes of DG hence
will have to understand the condition and the medications prescribed. The patient will be advised
to report any changes that may be noticed immediately.
Encourage the patient to consume a diet rich in fiber to help him manage constipation (Bae,
2014). These include food such as apples, oats and potatoes.
Moreover, emphasize the importance of physical activities and advise the patient on the exercises
that might be fit for him.

Reference
Ambrozini, Beatriz, Priscila Cervini, and Éder Tadeu Gomes Cavalheiro. "Thermal behavior of
the β-blocker propranolol." Journal of Thermal Analysis and Calorimetry 123, no. 2 (2016):
1013-1017.
Bae, Sun Hwan. "Diets for constipation." Pediatric gastroenterology, hepatology & nutrition 17,
no. 4 (2014): 203-208.
Nieuwlaat, Robby, Nancy Wilczynski, Tamara Navarro, Nicholas Hobson, Rebecca Jeffery,
Arun Keepanasseril, Thomas Agoritsas et al. "Interventions for enhancing medication
adherence." Cochrane database of systematic reviews 11 (2014).