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Note: This is a fictional patient assessed on 10-1-2019.

Setting

You are an intern at a local community pharmacy. Mr. Edward Ramirez is a patient of your pharmacy whom you are interviewing for the Community SOAP assignment.

Your questions to the patient are in bold and patient answers are italicized.

  • Good afternoon Mr. Ramirez, before we get started please verify your date of birth.

    • November 1, 1965

  • Thanks for sitting down with us, so that we can come up with any recommendations to optimize your medication therapies to improve your health. Any recommendations we have today, will be sent to your doctor. How are you feeling today?

    • Thank you for your help. My allergies have really been acting up recently and I have been having a runny nose, itchy eyes, and sneezing. Can you recommend an allergy medication? I also notice some burning and tingling pain feeling in both of my hands and feet. Other than that, I don’t have any other symptoms.

  • I am sorry you feel this way. We definitely want to get to the bottom of these issues! I can recommend an over-the-counter allergy medication. I want to ask you some more questions about the sensations you are feeling. When did those start and does anything make the sensations better?

    • The sensations started about 3 months ago. I think it is because of my diabetes because my parents had the same problem. I tried to take over-the-counter pain medications but those do not help my symptoms.

  • How would you rate your pain on a scale of 1 to 10, with 1 being no pain and 10 being the worst pain? When is your next doctor’s visit?

    • I would say the pain is about a 3–4 right now but sometimes it goes up to a 7. I will see the doctor next week.

  • I’m sorry you have been in so much pain. It is important for you to talk to your doctor about this pain at your next appointment or you could call the doctor’s office to see if you can be seen sooner. What medical conditions have you been diagnosed with?

    • Thank you, I will just bring up my pain at my appointment next week. My medical history includes type 2 diabetes, high blood pressure, and high cholesterol. I also had a mild stroke 6 to 8 years ago and was admitted to the hospital in December 2017 for sepsis from a liver problem.

  • What medical conditions have your immediate family been diagnosed with?

    • Both of my parents have diabetes and high blood pressure. My sister has breast cancer and my son has heart murmurs.

  • We would like to be sure you are on the right medications as well as have the correct lifestyle modifications for your medical conditions. Before we make medication adjustments, we would like to go over your medication list just to make sure we have ...

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