2. NAME: xxx
AGE : 43
SEX :FEMALE
WT : 68 kg
HEIGHT : 155 Cms
CHIEF COMPLAINTS :
FATIGUE, BREATHING DIFFICULTY, MUSCLE CRAMP , EDEMA
3. PRESENT ILLINESS :
CKD FOR PAST A YEAR FEMALE PLANNING DOSE LONG NECK.
BECAUSE OF CATARACT SURGERY DONE -10 YEARS BACK.
PAST MEDICAL HISTORY:
CHRONIC KINDEY DISEASE
PAST MEDICATION HISTORY
INJ . INFER -100 MG
INJ . TRANSFER - 400 U
TAB . TAXIMO - 200 MG
TAB . ULTRACETSEMI
TAB . AMLODEPINO - 2.5 MG
4. PERSONAL HISTORY :
NIL
PHYSICAL EXAMINATION:
PATIENT IS CONSCIOUS / ORIENTED
EDEMA
ON EXAMINATION :
TEMP - 98•6 F
BP - 140/ 80 mmHg
8. MEDICATION ERRORS:
NIL
DRUG INTERACTIONS:
NO DRUG -DRUG INTERACTIONS INTAKE OF
CARBOHYDRATES & VITAMINS RICH FOODS SHOULD BE
ADMINISTERED
ADR :
SWEATING, LIGHT HEADACHE, CONSTIPATION
9. ARAICO PHARMACEUTICAL | VACCINES
DISCHARGE ADVICE :
AVOID HIGHT SALT INTAKE
DO EXCERCISE
SOAP NOTES :
SUBJECTIVE - FATIGUE, BREATHING DIFFICULTY,
EDEMA & MUSCLE CRAMP WAS OBSERVED
OBJECTIVE - TEMP - 98.6 F
BP - 180/ 40 MMHG
10. ASSESSMENT - CHEST X- RAY & BLOOD UREA CLEARANCE TEST
WAS OBSERVED
PLAN OF TREATMENT - HEMODIALYSIS ( PERMANENT)
PERITONEAL DIALYSIS (NOT YET DONE)
PATIENT MUST AVOID INTAKE OF CARBOHYDRATES RICH
FOOD & CRUCIFEROUS SUBSTANCE SINCERITY DISTRUBS THE
ABSORPTION OF ACETAMINOPHEN.
ALSO AVOID INTAKE OF VITAMIN RICH FOOD.
SINCE IT DECREASES THE EFFECT OF NORVASC.
PATIENT COUNSELLING:
