4. SOAP NOTES
SUBJECTIVE : A 35 years old female patient was
admitted in hospital with C/O: Draining PV, pain in
lower abdomen, pain while micturating and
oedema on both legs.She didn’t had a significant
past medical & medication history. She was a
married lady.
4
5. OBJECTIVE
INVESTIGATIONS DONE: PICCL(+)E(+).
HAEMATOLOGY: Blood urea: 55(elevated)
o Creatinine:1.77mg/dl(elevated)
o Serum ferritin: 229.72(elevated)
o Haemoglobin: 11.1(decreased)
o AFI: 31.4cm(elevated)
o FHR: 123 BPM
5
DATE 10th
DEC
11th
DEC
12th
DEC
13th
DEC
14th
DEC
15th
DEC
TEMP N N N N N N
BP 120/70 110/70 120/70 110/80 120/70 110/70
PULSE 72 73 72 73 72 72
6. ASSESMENT
Based on the clinical evidences, the patient was
diagnozed with Hyperthyroidism, B/L pedal
oedema, Anemia, Polyhydramnios,Hypotension
and Post partum haemorrhage.
6
7. PLAN OF TREATMENT
7
S.No DRUGS DOSE DAYS
T.NAME G.NAME D1 D2 D3 D4 D5 D6
1 INJ. IVF Normal saline 100ml √ √ x x x x
2 T.Orofer XT Iron, Folic acid,
calcium
100mg
1.1mg
√ √ √ √ √ √
3 T.Neomercazol
e
Carbimazole 5mg OD √ √ √ √ √ √
4 INJ.Metrogyl Metronidazole 500mg
OD
x x √ √ √ √
8. 5 INJ.cal.gluco
nate
Calcium
gluconate
10ml
IV
x x x √ √ √
6 Packed cell 1 unit x x x √ √ √
7 Syp.Piriton cs Chlorpheniramin
e maleate
2tsp
tds
x x x x √ √
8 INJ.Lasix Furosemide 1amp
IV
x x x √ √ √
9 T.Dytor Torsemide 20mg
OD
x x x √ √ √
10 T.Misoprost Misoprostol 50mg
OD
√ √ √ √ x x
8
9. DRUG INTERACTIONS-
No significant drug interactions were found
ADR-
No significant ADR were found
9
10. PLAN OF TREATMENT
DISCHARGE MEDICATION -
1. T.Torsemide,
2. Syp.piriton cs and
3. T.Neomercazole
PATIENT COUNSELLING -
Take Antacids to relieve Heart burn & Nausea which may be
caused due to Polyhydramnios.
Furosemide-Furosemide will make you urinate more often, so
don’t panic.you may get dehydrated easily so avoid exposure
to sunlight .
Metronidazole-Skipping doses may also increase your risk of
further infection & development of resistance to antibiotics.
10
11. Chlorpheniramine maleate- Advise patient medication may
cause drowsiness or dizziness and not to drive or perform
other activities requiring mental alertness until tolerance is
determined.
• Advise patient to take each dose without regard to meals, but
to take with food if stomach upset occurs.
MONITORING PARAMETERS-
• Monitor the T3 & T4 levels for the control over the Thyroid
functioning
• Monitor the Hb & serum ferritin levels for the control over
Anaemia
11
12. LIFE STYLE MODIFICATIONS-
Anti-oxidants like vitamin C (lemon, orange, amla, sweet lime
etc.), vitamin E (meat, liver, fish etc.) must be suggested as
these reduce the iron from ferric state to its ferrous state
(since iron can be absorbed only in its reduced form).
Avoid sea foods as they contain high iodine content.
Broccoli, soya products, cabbage, cauliflower, strawberries
comprises a good diet for Hyperthyroidism
FOLLOW UP-
Review after 10 days
12
