PATIENT PROFILE FORM

Department of Pharmacy Practice, ISF College of Pharmacy, Moga-142 001

Routine Biochemical Investigations:

Patient Name Code: IP Number Code: Ward: Unit:

Sex: Age: Date of Admission:

Height: Weight: Body Mass Index: Date of Discharge:

Complaints on Admission:

Physical Examination:

General :
Central Nervous System (Orientation/Head/Consciousness/Calm/Aggressive/Depression):
Cardiovascular (Edema/ Pallor /Koilonychia /Cyanosis /Clubbing / Icterus / Lymphatic Node enlargement):
BP: PR: Heart:
Body Temperature:
Respiratory (Nose/Thorax/Respiratory Rate):
Gastrointestinal (Abdominal/diarrhea/constipation/Pain):
Senses (Eyes/Smell/Hearing/Pain/Taste):
Genito-urinary system (Urination/Uterus/Testis):
Others:

Medical History: Family Medical History: Medication History:

Allergy History (Drug/Food/Herb/Substance): Social History (Diet/Addict):

Provisional Diagnosis:

Parameters Observed value Normal Range Parameter Observed Value Normal Range
HEMATOLOGY: LIPID:
M 14-18g/dL Total cholesterol <5.2mmol/L
Hemoglobin
F 12-16g/dL LDL <4.13mmol/L
Hemoglobin A1c - HDL 1.03mmol/L
RBC M 4.3-5.9x1012/L Triglycerides <1.70mmol/L
M 0.39-0.49 DIABETOLOGY:
Hematocrit
F 0.33-0.43 Fasting Glucose 70-99 mg/dL
M 0-15 mm/h Pre-Prandial Glucose 70-130 mg/dL
ESR
F 0-20 mm/h Post-Prandial Glucose >140 mg/dL
M 35-155ug/dL Random Glucose 80-120mg/dL
Iron
F 50-170ug/dL RENAL:
MCV 76-96fLa Blood Urea 15-45 mg/dL
MCH 27-32pg BUN 5-17 mg/dL
MCHC 31-35% Sr. Creatinine 0.8-1.3 mg/dL
TLC 4000-10000cumm Sr. Uric acid 2.4-7.0 mg/dL
Neutrophils 40-70% Sodium 135-155 mEq/L
Eosinophils 1-4% Potassium 3.5-5.5 mEq/L
Basophils 0-0.5% Chloride 98-107 mEq/L
Monocytes 2-8% Calcium 9.2-11.0 mg/dL
Lymphocyte 20-45% Bicarbonate 23-28 mEq/L
Platelets 1.5-4.0 Lakh/cumm UROLOGY:
PTI 90-100% pH 5.0-9.0
BT 1-4 min Sugar 100-260 mmol/d
CT 3-10 min Protein 150 mg/d
PT 9-12 sec Albumin
TYPHI(widal card) +/- RBC 0-3 cells
LIVER: WBC 0-1 cells
Bilirubin-Total 0.3-1.1mg/dL EP Cell Nil
Direct 0.1-0.5mg/dL Puss cell Nil
ALT 5-40 IU/L Crystals 0-4
ALP 60-150 IU/L Casts
Unconjugated 0.2-0.7 mg/dL OTHER INVESTIGATIONS:
THYROID:
T3 1.2-2.1nmol/L
T4 70-151 nmol/L
TSH 0.4-5 munits/L
Free T3 3.7-6.5pmol/L
Free T4 10.3-21.9pmol/L
Interpretation in Consultation with Physician:

Final Diagnosis in Consultation with Physician:

Drug Treatment on Admission:

Generic Pt. Compliance

Brand Dose
Date
Name
Name + Strength Route Frequency
(mg/g/%)
Response/Investigations/Pro
Indications gress
Drug Treatment on follow -up:
Generic Name + Dose Pt. Response/Investigations/Progress Compliance
Date Brand Name Strength Route Frequency
Indications (mg/g/%)

Medications on Patient Discharge:

Dose Note
Date Brand Name Generic Name + Indications Strength Route Frequency
(mg/g/%)

Patient Counseling (Consultation with Physician/Preceptor):

Pharmacist Interventions:
 Department of Pharmacy Practice
ISF College of Pharmacy, Moga-142 001
Case Evaluation Form

Student Name:
Class:
Case No:
Data Collection Date:
Presentation Date:

Parameters Marks
Data Collection
Interaction Ability
Case Understanding
Presentation of case
Discussion of case
Drug Therapy changes
Patient counseling
Communication
Review Writing Skill
Overall Assessment

Max Marks 10

Comments/Remarks:……………………………………………………………………………….

………………………………………………………………………………………………………….

Student Signature:

Preceptor
(Name, Signature, Date)