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
INVESTIGATIONS DONE: PICCL(+)E(+).
HAEMATOLOGY: Blood urea: 55(elevated)
o Serum ferritin: 229.72(elevated)
o Haemoglobin: 11.1(decreased)
o AFI: 31.4cm(elevated)
o FHR: 123 BPM
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
Based on the clinical evidences, the patient was
diagnozed with Hyperthyroidism, B/L pedal
oedema, Anemia, Polyhydramnios,Hypotension
and Post partum haemorrhage.
7. PLAN OF TREATMENT
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,
√ √ √ √ √ √
Carbimazole 5mg OD √ √ √ √ √ √
4 INJ.Metrogyl Metronidazole 500mg
x x √ √ √ √
8. 5 INJ.cal.gluco
x x x √ √ √
6 Packed cell 1 unit x x x √ √ √
7 Syp.Piriton cs Chlorpheniramin
x x x x √ √
8 INJ.Lasix Furosemide 1amp
x x x √ √ √
9 T.Dytor Torsemide 20mg
x x x √ √ √
10 T.Misoprost Misoprostol 50mg
√ √ √ √ x x
10. PLAN OF TREATMENT
DISCHARGE MEDICATION -
2. Syp.piriton cs and
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.
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
• Advise patient to take each dose without regard to meals, but
to take with food if stomach upset occurs.
• Monitor the T3 & T4 levels for the control over the Thyroid
• Monitor the Hb & serum ferritin levels for the control over
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
Review after 10 days