INTEGRAL UN

DEPARTMENT OF P IVERSlTY
FACULTY OF PHA~ ~~~A YCY PRACTICE
. . LUCKNOW

PATIENT PROFILE FORM ICLERKSHle)_

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UG (MED ICAT ION) HISTO RY : ~
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SURG ICAL HISTO RY: "JI-:_

SOCIA L & OCCU PATIO NAL lllSTO RY: t~ .>,

PERS ONAL HABITS: Diet: ~en -Ve

Alcohol: Any other:
ADDI CTIO NS-D URAT ION Smok in~:

ALLE RGIE S: Nane,

io Drowsy/ Comatose
PHYSICAL EXAMINATIONS: Sensorium: Consc
Cyanosis: Yes i ,-_. \
:. Yes /~ ~ Icteru s/Jaun dice: Yes /)s-8
GENE RAL EXAMINATION: P-I-C -C-L- E: Pallor
Clubb ing: Ye s/~ Lymp haden opatb y: Yes l ~ Edema: Yes / "i,-
D9 D10 D11 D12 Dl3 014 DIS 1

D4 D5 D6 D7 D8
VITA LS
BP(m mHg )
PR / Min
RR/M in
0
Temp. ( C)
Fluid Intak e(ml)
Fluid Output(ml}

HEENT
CVS

RS
GIT
GUT

BXT

AL DIAGNOSIS:
R.i hl D;abel-tc Fool--
 --,
LADO RA TORY INVE STIG ATIO NS
I HEMA TOLO GY II 2 KIDN EY PANE L I l Lll'ID PROFILE I l D
RBC(M ale> I 4.3-5.9xt<J6tµL Urea 1~7mg /dl !) 6 (;.c, ·101111-C <200 mg/dl 1-/', ,} I
RBC(F em) 3.5-5.0>'108/µl BUN 8-20m!)'dl TGs(F) <150 mg/dl
l
Hct(M ale) 39%-49 % Creatininc 0.6-1.2 mgldl Y, \ I LDL 70-160 mg/di,
3
Hct(Fe m) Uric acid <7 mg/dl IIDL 40 mg/dl 1'1 •1,,
33%-43 %
4
Hb (Male) 14-18 g/dl 13,3 cGFR ~120m Vmln LIVER FUNC TION TEST
Albumi n 3.~.8g/dl AST(SG OT) 0-35 units/I.. I I Ir, 5
Hb{Fe m) 12-16g/dl
Ill,,'->
-
Globulin 2.3-3.5 gldl ALT(SGPT) 0-35 units/I.. 6
MCV 76--100 pm3
Sodium 135-145 mEq/1.. ALP 30-120 unlts/L 7
MCH 27--33 pg
Potassium 3.5-5 mEq/1.. GGT 0-70 units/L
MCHC ~7g/ dl 8
Chlorid e 95-105 mEq/1.. 11Jiirubin-total 0.1-1 mg/dl
ESR (Male) 0-20mmJh
Calciun Hotal 8.5-10.5 mg/dl 131lirubin-chrecl 0-0.2 mg/dl
ESR(F em) 0-30mm!l'l
Alk phosph atase 30-120 U/L CARD IAC 1310J\ 1ARKE RS 10
\-v'BC 4-11 X 103}µl
2.5-4.5 mg/dl CK-MB 5-25 IU/L
Neulro phils 40%-70% Phosph orous DISCH ARGE ~IEDl C ATlON S
22-29 mEq/L cTn! 0 01-0.04ng/mt
Lymph ocytes 20%-40% Bicarb onate l\1cdic incs
Homoc ysteme 4.6-15µmoUL
0%-11% URIN E ANAL YSIS
To"1 . Au_r11 er,-f.fr> c, Q Ei nJ
jMono cytes
Yellow/ amber \' LDB 140-200 U/L
Color
I Eosinophils 0%-8% ,,. , ........,. MISCELLA'NEO'US
BaS()phils 0%-3% Spec. gravity 1.002 to 1.030 I
PLTCo unt 150-45(),c10¥JL pH 4.5-8
,..,., / TSH
.
2-10µ\J /ml
rob. po.n - D uom ~ D
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T4 ~- '" 5.4-11.5 j,g)dl:
To.b. °7'.e..,""!oc; ot !, ~I
Protein 30 to 130 m!>'day I,
Iron 60-JIO mcpt.
S6 I• P.Lip ~ , 0-160 untts/l. .•
RBCs
~

j BLOOD GLUCOSE .c,.1 ~A 0-4 ng/ml . ~:.

/FBS l70-a9 ff9'd. WBC S5 -----~
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c.b · Pr-to 1-
Sugar Negative '
/PPBS <160mgicl.
Nil ,.,. \ RADI OLOG Y/ BIOPS Y
/RBS <1&'. >~ J& ~ Casts '.

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Ath '2 15 cb
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FINA L DIAG NOS IS:

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Patient Profile Form

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DR l G ( \ 1 E D C \TION ) HISTORY : FA MILY HI STORY: JI ,g
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S URGI CAL IIISTORY: /\)On(! I
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SOCIAL & OCCUPATIONA L HISTORY:

PERSON AL IIABJTS: Diet: Ve e d.>aan

ADDICT IO"IS-Dl ' RA TION Smoking : Alcohol: Any other:

ALLERG IES: /I/one

PHYSICA L EXAMIN ATIONS: Sensorium : Consciou Drowsy/ Comatose
A
lcterus/J aundic e~/ ~o Cyanosis: \es / ~
GENERA L EXAMIN ATION: P-1-C-C- L-E: Pallor: Yes/ ~
Clubbing : Yes/~ Lymphad enopathy : Yes/ JS.iv Edema: Yes / ~

D6 D7 D8 D9 D10 D11 D12 D13 D14 D1S

,.IT.-\LS DI D2 D3 D4 D5

BP<mmH g)
PR / Min

RR / Min
Temp. (°C) fl I,:
Fluid Intake (ml)
Fluid Output(ml)
HEENT
CVS
RS I
GIT I WNL
GUT
EXT
CNS
Others

PROVISIONAL DIAGNOSIS: tllolf lETi iillgr ~ c CBA :JllDt,E -c otJffiucTive!JnuNDIC.t

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HEM ATO LOG \' ~~1.,1 .(~ ~ 1 Cr Ilfil.
Un.-a ll!•t· nwd -l~ - -
4.3-5.9•108/pl <150 mgldl ·- ~
. " RBC (Mal e) I<,, ti 1 2
B\JN 8.J0 mgldl -l'dl- . - --
RBC (Fem) 3.5-5.Q>tt()O/pl · - 11'1 - - - 70 -IM!m -l Gp': 1on[f1_ ,;m ll.L ..- -
. ' 06-1.2mgidl 1
('t.,;11111111-, mg/dl q____.
,.. Hcl( Male ) 39% -49% 111 ll ~O .f.'; .H{}_(l e_
\In" 3,•1,I <7 mg'dl 1
~ Hct (Fem) 33%--43'14 U\1 -:RH NCr tO;' I.IE SI
"'->l'R 9Q-120ml'mm 8'] o 5
Hb(M ale) 1+-18g,111. \Sl (Stil Hl D-35urnts/L
Alt-um,n 33-4 .89/d l I '3 Q ~
Hb(F em) 12-16~dl. 1,5.,Z \I 1 1S(WI I D-35 urnts/L
~ 2 3-J.5 gldl -;;-
Glc't:-uhn 3D-120 units/I.
MCV 7fHOOl,ffl' ,\I I' ,-'....
S<>Jmm 135-1-45 mEq/l D-70 urnts/L
MCH 27-33 P9 t;t, 1
Potassium 3.5-5 mEq/l .', C ~
33-.37 g/dl Bli1ruh111-101al O1-1 mgldl
MCH C 95-105 mEq/l 9
Chlond-, B1hrub111-dircct D-0.2 mg/dl "
ESR (Mal e) 0-20 mmlh
Calc ium- total 85-10 .5 mg/dl 3 0
ESR (Fem } o-.30 mnvh C.\R DIA C" BIO MAR KER S
All phos phata se 30-120 U/l
4-11 x1()J/µl CK-MB 5-~S IU L O'-S
WBC 2.5-4.5 mg/dl - DIS CHA RGE \lf,D K ,\Tl
Phosphorous I Fr~ • 0...T
40% -70% cTnl O01-0 04ng ml Oc:>q RL
j Neut roph ils 22-29 mEq/l
Bica rbon ate 46-1 51nno1L
~Med icin es
/ Lym phoc ytes 20% -40% llom ocys terne r•
UR INE AN ALY SIS 140-200 UL -r-:-b ('
;.-1 r,~rr.q ~f.,i
/Mo nocy tes 0%-1 1% LOH a . 7,.: ..
Color Yellow/ amber
/ Eosi nopb ils j 0%--8% I\ITS CEL LAN EOU S
Spec. gra, ,t) 1.002 to 1.030 'ob . Pon '-' o m nI ~ b
0%- 3% TSH 2-10 µUlmL ,., ~J !
/ Baso pbils 4.5-8
pH 5.4-11 .Sµg /dl ,13b . A ! o -z. , c,
/ PLT Coun r , 150-450ir10>/µL T4 j
Pmte m 30 to 130 mg/day
/ Iron J 60-l 80m cg,L P. Lipa se ~160 units/L
RBC s <6 0 ,n i- t {3 Ct C. ~ - :. t.- E\ ~
/ BLO OD GLU CO SE PSA 0--4 ng/ml
WBC :S5
/ FBS / 70-9 9 mgldL
Sugar Negative
/ PPB S / <160 mgldL R~D IOL OGY /BIO PSY .
Casts Nil 1
/ RBS / <160 mgldL Mf?O> - (?/,,lr/nt- fltJLo'l ,'[J
, C,)'stals Nil ~ri ,,,..
/Hg bAl c / <4-5 .6% j .. !!Ct~~ • ~I).. , I:
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PATIENT NAM£.
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INTEGRAL UNIVERSITY
DEPARTMENT OF PHARMACY PRACTICE
FACULTY OF PHARMACY, LUCKNOW.

PATIENT PROFILE FORM !CLERKSHIP)

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DEPTJ\JNIT:$1m..q DOA: Ill Jtol~.3 I DOD: :2 fr r r~ 3'
~ADO: TH~l<AfVJr,u LUC.kND(i) AGE: 3oY
.REASONS FOR A
GENDER, Mak WE1G11T, SG k~ ni::1G11T ,
DMISSION/ CHIEF COMPLAINTS (CC):

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l~STORY OF . '
al'<.rgli. I I/ JREsE,T IL,LNEss (111'1): Pf flJ[Jf. op.'1.}fV/en_lltj- PAST MEDICAL HISTORY (PMII):
llb _r a)l./,t oocl<. wnen he c&aelap@'cl pcun. m
;1orrwn t.,J/(/cn WM uufden fn on
Ke/'-£ /JJ{O(J'lff'fS 1 tJf:.
~anl:l. ltna6fe Jo pal.).. sfoof. J ffofwu s,ncesda.y ~.
No 1-!,'o -/9rCttttr;i't G,recfi~/ e/:
DRUG (MEDICATION) rns·, OHY: FAi\DLY lllSTORY: 'V / S

SURGICAL msTOR\, v,·L

SOCIAL & OCCUPATlONAL HISTOR\: 10 ti.I

PERSONAL HABITS: Diet: (Je7ilaJuan

ADDJCTJONS-DUIUTION / Smo!,iu~: Alcohol: • \ ,\II) othci-:
ALLEnGJES: tvo I
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-
PHYSICAL EXAMINATIONS: .Sl•mo1 i11111: l"onjdou1 / D.-o"'>' /CoauCOIC
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GENERAL EXAMINA1 ION: J>-J-C-C-IA!: Pallor: \ 'rs/lli,o kctnai/Jaundkc: Yrs/ l)o Cyano!ilt1: ,. l'tt {.No
Clubbln;: '\ et /ro l.)ntpl111dtno1>:alh): \ 'l'S / No l':th.-mll: \'t•• /1No
\
VITALS 1>6 ()9 D10 DI I Oil DIJ l>l4 l>l~

IJP (rnmllg)
PR/ Min
RR/ Mm
Temp. (0 C)
Fluid Intake (ml)
flwd Output(rnl)
HEENT
CVS
RS
arr
OUT
8XT
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KlDNE\' PANEL ) ) )
~-3-5.9x10ll,,i.: Urea 2
11 18--47 mg/dL
LIPID PROFILE PATIENT PROGRESS
3.5-5.0x 1()11,t_ 2 I I Day I
BUN Total-C <200 mg/dL
(Male) 39%-49% 8-20 mg/dl
TGs (F)
- 1
Creatinine 0.6-1.2 mg/dl <150 mg/dl
lic:t(Fein) 33%-43% -
Uric acid LDL I 70-16q m~dL 2
Hb(Ma)e) 14-18g.ldl <7 mg/dl -J
eGFR HDL I 40 mg/dL
Hb(Fem) 12-16 gldl. 90-120 mVmln
LIVER FUNCTION TEST
-4
MCV Albumin 3.3-4.8 g/dl
76-100 ,nn3 AST{SGOT) 0-35 unffsll.
MCH Globulin 2.3-3.5 g/dl o I
27-33 ALT(SGPT) 0-35 units/l
Us-
Sodium 135-145 mEq/L 6
MCHC ~7g1dl ALP
Potassium 30-120 unffs/L
ESR(Male) 3.5-5 mEq/L -7
0-20mmlh Chloride GGT I 0-70 unitsll
ESR(Fem) 95-105 mEq/L
0-30mmlh Bilirnbin-total I 0.1-1 mg/dl 8
Calcium-total 8.5-10.5 mg/dl -
WBC 4-11 ><103/µl Bilirubin-direct I 0-0.2 m9idl 9
Alk phosphatase 30-120 U/L -
Neutrophils 40%-70% CARDIAC BIOMARKERS
Phosphorous 2.5-4.5 mg/dl 10 / ,.,
Lymphocytes 20%-40% CK-MB 5-25 TU/L
Bicarbonate 22-29 mEq/L
Monocytes cTnl 0.0 l-0.04ng/mt DISCHARGE MEDICATIOXS
0%-11% URINE ANALYSIS Hojijocysteine 4.6-15 µmo l/L M edicines Dose I RL j frq I Dur
Eosinophils 0%-8% Color Yellow/ amber , - ' ·L 1 1!40-200 U/L
Basopbils 0%-3% ., --1i....:. ,
Spec. gravity 1.002 to 1.030 . ·1....::1 MISCELLANEOUS Jj! r f!'lor;O':,~ 1.Q •. IC'
PLTCount 150-450x11P1p1. I !3.Jo pH 4.5-8 v , I
2-10 µUhnl,'
1ron 160--110 mcg/L Protein 30 to 130 mg/day 5.4-11.5 µgld,l.i
BLOOD GLUCOSE RBCs S6 0-160 lllffs/L,._ ErJ :on 'I~ m3 "i""t•cl Li!--/ ll 6 c~
WBC S5 lnJ -:.ms~.: urriat't-t .. ,,. · -' -··
·~! l}-4ng/ml !?
--g- Neo::itiv..
e
Ims 1--. I I Is.~, Casts i---·--·- I •.,J1 IRAJ1ibToci' •m:sv I I I . 1 r -0
Crystals
PPBS <,....., NI , •" ' . I . .r,f,v /o .!.f. _,i., I ,r,.,. c
"~ J ,,. ....
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DIAGNOSIS· C ,;,· FOLLO" UP. <' ,,
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MEDICATION CHART
Dose Route 5 6 7 8 , 1 :; = 1 ;:; 1 ;:; 1 :; 1 ;:;;
Generic Name I Indication j II II Freq.
Freq I 1I 2 I 3 I 4 I
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 INT EG RA L UNIVERSITY ~~~:,~
PRACTICE
DEPARTMENT OF PHA RM ACY
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ORY :
SOC IAL &OC CUP ATI ONA L HIST
\
PERSONAL HABITS: Diet~ /\Jon vf'
Alcohol: Any other:
ADD ICT ION S-D URA TIO N Smo kii:g :

ALL ERG IES : tV one.

·
orium: Couse· us/ Dro wsy / C.omatose
PHYSICAL EXAMINATIONS: Scns
Icte rus/ Jaun dice : Ye s/~ Cyanosis: Ye s~
C-C -L-E : Pallor~ Y e s ~ i
GEN ERA L EXA MIN ATI ON: P-1-
Clu~1?J?g: Ye s~ Lym pba_d eno path y: Yes !J'39 Ede ma: Yes I ~

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D13 D14 015
D2 D3 D4 D5 D6 , D7_, , os D9 D10 Dll D12
VITALS D1
BP (mrnHg)
PR /Mi n
RR / Min
Temp. (0 C)
Fluid Jntakc (mJ)
Flui d Output(mJ)

HE EN T Nfl/J
CVS

RS
GIT
GUT
EXT
CNS

NAL DIAGNOSIS: CHfJ L£ Lr TH rfJ SE S ')

 ~ORY INVESTIGATIONS ., > ;, ) J J J J J ) ) ) ) ) )
~TOLOGy \1 12
KlDNEY PANEL 2 I -..!:!PiD PROFILE ji /l / r---,. _ _PATIENT PROGRESS
lt8C(Male) I 4.3-5.9•10'1µL I I I Urea
1~7 mg/dl
3.5-5.0x 10llµL Total-C <200 mg/dl
BUN 8-20 mg/dl
H~ (Mate) 139%-49% TOs (F) <150 mg/dl
Crcatinine 0.6-1.2 mg/dl 2
Hct(Fem) I 33%-43% LDL 70-160 mg/dL
Uric acid <7 mg/dl 3
Hb(Male) HDL 40 mg/dl
1-'r18W(il eGFR 90--120 mVmln LIVER FUNCTION TEST 4
Hb(Fem} 12-1sg1dl. llJ,C Albumin 3.3-4.8 9/dl AST (SGOT) 0-35 unlts/L 5
MCV 76-100pm' Globulin t----1-...L..i.~_L..21..PI/. t"; ( 0 rllr I"' I I": ~ ('
2.3-3.5 g/dl ALT (SGPT) 0-35 units/L
MCJ-t 27-331)!? 6
Sodium 135-145 mEq/L ALP 30-120 units/L
MCHC 33-37 gldl Potassium 7
3.5-5 mEq/l GGT 0-70 units/L
ESR (Male) \ 0-20 mm/h Chloride 95-105 mEqll Oilirubin-total O.H mgldl R
ESR (Fem) I 0--30 mm/h Calcium-total 18.5-10.5 mgldl 9
Bilirubin-direct 0-0.2 mg/dl
WBC I 4•11>-10 3/µL /\lk phosphatase I 30-120 U/L CARDIAC BIOl\lARKERS JO
Neutrophils I ~0%-70% l'hosphorous 2.5-4.5 mgldl CK-M13 5-25 IU/L
Lymphocytes I 20%-40% Bic::irbonate 22-29 mEq/L cTnl 0.0I-0.04ng/ml • DfSCIIARGE Mf.DJCATi:J.\:-,
Monocytcs I 0%-11% llomocysteine 4.6-15 ,mol/L I l\ledicincs Dose J::1. ' frq I Dur
URINE ANALYSIS 1
Eosinophils I 0%-8% Color YeUow/ amber LDH - 140-200 U/L
Basophils 0%-3% Spec. gravity 1.002 to 1.030 MISCELLANEOUS ~ gorr.p•/1 r. '
PLT Count 150-450x10S/µl ~f()O I 4.5-8 TSH 2-10µ\Jhn( . ';: t T
IPH
Protein 30 to 130 mg/day T4 5.4-11.Sµg/dl T, (<pp,,-,.._
Iron J60-1 80 mcg/L
BLOOD GLUCOSE RBCs S6 P. Lipase 0-160 unlts/L 1 1 lI T
IWBC S5 PSA 0-4 nglml
FBS 170,-89 mgdl ~5 I
PPBS <160mg.f<L Sugar Negative
Casts N~ RADIOWGY I BIOPSY
RBS <160f1911. r '-~J
I
I. I. I
<4-6.6% Crystals Nil
HgbAlc
flHoLr L1 nu flSI s . /~ · j FOLLowt·r: '· ·-· ~ ~
\ FINAL DIAGNOSIS: _ _ _ _-,----,-----r--,----'---.-
MEDiCATiON CllA!lT : .. ~, "I 7 5 J ~ I E · = ,;:;, :: I .:::;;
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_ 1gn. ~f S~d~nt:
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N
 H"'\
1 ,.--..,
INTEGRAL UNIVERSITY
"' DEPARTMENT OF PHARMACY PRACTICE
FA CULTY OF PHARMACY, LUCKNOW .
"I
PATIENT PROFILE FORM~ill.rnt!fl
~
ADD :
Ir N(l: / 3 (, 't OFPTJ l lN IJ : _] UOA, fJ /9 /rJ?, DOD: II 9 ~3
A<:1,, 'I I y , ;.:Nont: f
")
REASONS FO ADl\llSS IO l'i/ CHI EF l 'Ol\1PLAINTS ((T ) :
I Wt,;l(, IIT: IIE IGIIT :

~
Redne~<J one! scur.//in!J ·,u; dayt
--. 7 ~r-'_!__:n iilf...__&c_~k.._ ___'__ .-------------------;
r-;;;=::::--.:--=--~"~u.!..!.n'!.J.
' HIST(?RY OF PRES E T ILI .I\ FS!-. (lll'l) : PAST MEDICAL HI STORY (PMH):
--- pcd,~n/. t1flos al'(/1")('n//~ r1.1e// C rlayr bock
She df!ve/nr ~eclnesr Ond $CJ.,1e//1h~ . <?//('(, No H / o · f 17 rv , D('(J , 7 8
' '""I ..J ~ _/ C

-
......._
DRUG (MEDICATION) IIISTOR, : FAMILY HISTORY :

suRGICAL HISTORY:
f\./1'l

Nt ne
N~ H / O rrJe.('!tca l,~n
-.. SOCIAL & OCCUPATIONAL HISTORY : [.O l,J

PERSONAL HABITS: met:s Ve.

ADDICTIONS-DURATION Sa!oking: - Alcohol: - Any other: ..
ALLERGIES: /Jl)ne__
PHYSICAL E~UNA TIO NS: Scnsodum: Cons ious / Drowsy /Coll\lltose

GENERAL EXAMINATION: P-1-C-C-L-E: Pallor: Yes/~ . lctcrus/J._aundice: Yes/~ Cyanosis: Yes / ~

Clubbing: Yes / ~ Lymphadenopathy: Ycs / No Edema: Yes / ~

-
. . I.,--""
,
~·
VITALS
BP (mmHg) ,,o ~o
D1 D2

-I
D3 D4 D5 D6 ,, D'/ . ·D8 D9 D10 D11 D12 Dl3 DU D15

PR/Min ";J/y j -

RR/Min I~ I -
Temp. ( C) Ill~
0

fluid Intake {ml)

fluid Output(rnl)
HEENT
CVS

RS
GIT
GUT

EXT
.
CNS
Others

IONAL DIAGNOSIS: tysf fJn f-he tack

 ) )
:·.-.x- itt.. -~n .;-. . , , ') I/ , ) • - ~
.. -••-•• "'VIC~TIGATIONS PA Ili:NT PROGRESs
:t;:s:~, .,_-l -., -.. -~TOLOcy jl j2 J KIDNEYPANEL , , I
u,m,ao,,t, , , ro,, 1 .,ogr..,
,j, i
,_· ·· be~_I I 4.3-5.0.,..,,, I I u, .....
' · ,a - 18-47
,o.... , mq/\ll •m .n <200 •"'-
T""'i-CLIPID PROFILE ' n ,
BUN --~ - Total-C
<200 mg/dl
... · ____ .. . .. .. IN e,20 ...,,,, ....,__ (F)
TGs(F)
TGs <fSO mg/dl / /, ", " , , I' _till
_ • I_ ' I - ,
Creatinine <150 mg/dl
~ ·•- ·
lo.s-u
"6-f.2 """'- IQ ,;j LDL 71)..160 mow , : 2
Uric acid 70-160 mg/dL
ar.icf HIii_ : ...,mmm '
I <7-~ mg/dl
... , , HDL
eGFR 40 mg/dL 1
l - --- - ---;,, ·--
90-120 mVmin I I .-.:::.~~;;;;_-~~-~.vn ll',~I I I- - - I: 43
nD(Male ---- ---- ---- LIVER _ ,no, __ ...
_ FUNCTION TEST ' '/71 11 S
..... .....
Albumin ' . ,,
...,_) 3.~.8g/dl 1
A<> -U• 1 "" 1 ,,,_.,_1 !-~ I v·w u,11,orL I C.
I~~
' AST(SGOT)
Globulin 0--35 units/I.
2.3--3.5 g/dl
-~•. .... Sodiu111 " ' - " ""' I' I' I..,
ALT(SGPT) I 0--35 un1ls/L
• - """"' I c,, <OI 'I "
135-145 mEq_
lvvu1u1n
I1135-145mEa/l ALP ---r;;--~::;:;;--- r-
MCHC 1-:i'> .,,. _,.,. -- ---•M•..
Potassium I.,,..,-;, mt:Q/L .
= I I 13.5-5 mEq/L , , !cc, 30-120 unlts/L , --- •I
-ESR (Male) 10-20 mm/h I I I Chloride ··
J~S-1n~m~nn
GGT 0-70 units/I. 1
95-105 mEq,~ 1 1 I
Bliirubin-total 0.1-1 mg/dl 8
ESR!Fcm) I0-30mm/h ---------
Calcium-total l!l5-105mo/dl
8.5-10.5 mg/dl I I ln.L-L C ,. --- r • I I
B1hrubin-direct 10-0.2 mg/dl I f--9
WBC 14-11x10•1µL Alk phosphatase 30-120 U/L
--------------, ... I("U"l"VUIL I I ICARnrArnrnMADVIC'nC'
1 1 I rio
Neutrol)hils I 40%-70% CARDIAC BIOMARKERS
Phosphorous 2.5-4.5 mg/dl
LymphOC)1es f 20%--40% CK-MB 15-25 IU/L
Bicarbonate 22-29 mEq/L cTnl 0 01-0 04ng/ml DJSCIJARGE MEDICATIONS
MonocyteS I 0%-11% URINE ANALYSIS Homocystcin~ . I 4,6-15 µmoVL M edicines I »- RL frq I Dur
Eosinophils I 0~% Color Yellow/ amber
Ba50!>!tils 0%-3% Spec. gravity
, :ttni · · · ~ ·. 114,o-700 U/L
1.002 to 1.030 MISCELLANEOUS T , Rm,')x_(L-!~,,e lo s o IGD
PLTCount 1150-450•103/µt. pH 4.5-8 TSH I2-10 µU/mt
Iron 60-] 80 mcg/L Protein 30 to 130 mg/day I I
l,, 5.4-11.5 µg/dl: T. 7e'--fidcL ~f u BD
BLOOD GLUCOSE RBCs S6 0-160 unlts/L
I ~
FBS I
70-99mg/dL WBC S5 0-4 ng/ml Cap. lb.n ./-cp 4, o I 01>
PPBS <160 mg/cl. Sugar Negative
RBS rl , •
<160 mg/ell Casts I /<I I I'-,..'
NH T t C -:... I "'~.,/\
I .._..-,
HgbAlc <4-5.6% Crystals Nil
() .
FINAL DIAGNOSIS: FOLLOW l.JP: ~0 '
C<j_ s/ tJn fh <!; 1/ock·
MEDICATION CHART
7 8 9 I ; ;: ~ :;: I ~
Indication Dose I Route I Freq. 2 I J I 4 5
J SN 1 Drug Brand Name Generic Name
V- I 1..-/ I \.

I
·~
V Iv I <-

0 .,,...- _, \. j L-
l/ 0 0
t. ,
() ~ I \_ \
Cl

Sign. of Preceptp~ <w) J',

r,.; '\\"'
\; - t\t>- 1
Name & Sign. of Student: /-?,v\

.__tcutU#.WWW.
1_1~,
~;:;:::'(M~'."~''
lkttl'~) 33~3%
·~·-•
~;~ _ [l:'.j-
e __,,......
I·· """""'~
, ,,. -1~f::?~: , i[::J;g_tj
..,. .~~ .....
O
: :f=:J.~ l~!;. ~.c~~ -"~
••yv:,
!if" , ._
4
llh M-1(') 14-18
~----- -----..~ ·-t::.-..:JI___ ;,""' "'"j- .'-"-''·-·-· ·- l:.:«>;'.!
·_- .
llh P~111)
- ~ - --f+WUJ- tt},110111~
. ~ - U Ytft Jl lNCTJ()]'lf :rr~r
:xi::.,~~·--..,.'
Ml'\' 70-100 \1 ~ ,~,-,,rm ,, qr !11, ... B.M 1..-hll l\ .
---,-,-.~---
Men u~, __ ~~"!!... _ tM~mcg,i _ , tililfcm:{~~- ~,:· _:3
IIIL'lll' _ 33--31 g/d\._ __ .t••t')_"_!!ln}_ _ 3.5{,mC /\.
ls~'.<•L\)L 0:-~0_n~~ l'hh!_!!,l~ P5-105 l'll~Q1 1- t . ~ ::::::·..:·••ro:" ,, E
BSR Fc111) ~O 01mn1 __ l'ulc1um-1"1nl 85,105 n1t!_
~--- _4•11•10'/111__ _ __ A.!l_1>h1~11ft,!_ ~
N,·111r.11hlls ~ 0% _ _rl~ hnt!'I'!... __ _2_,_5·:!_5~
Lympho~~ l~s 20%-40% llknrhonn1r 22-29 mEq ·
Monoc, t,•s I 0%-11'1!, l ,.,_ " I I llR(NE ANAL\'SIS r.;;.~1·
Eos11101>l11ts I 0%-8% "--
Color Ytllo\t,l 1mt,e,
nnsophils 0%-3%
PITC011111 S~ gravlt)' 1.002 to Ul30
ill 4.5-8
Iron I 60.. l RO mop/I.
l'm1r1n 30to t3Qn,~ '
BLOOD Gl,UCOSE
RRCs ~
FUS 70--99 mg/dl \VB(' S5
PPBS <160mgld. Sugor Negalive
RBS <160 mg/dL C'a.,1s NI
HgbAlc "'4-5.6% Crystnls NI

FINAL DlAGNOSIS:
MEDICATION CHART Ce bl} I ht! .l;o,k
SN I Drug Brand Nnme Generic Name l11dic11tion
D,m I R<>ult I J t-
, C)

l I,, C' "\ JI

l' ' /"\

-1-~ - +

Name & Sign. of Student: 'q:n. 4,1ft'n-.:c ~J

=-~--~--:;;,-~(;;:;;ii#ili .:,,,, ...

 INTEGRAL UNIVERSITY
FACUL TV OF PHARMACY
LUC~NOW
Patient Profile Form
(Pharm.D. Internship)
/b,J
Al>D :
~::;-:-:~L.L:.JU.l~(D.-1.ucl.n_a1Jl. - I II' '10 :

"'·· · t/1.J
IISSIO'\'/ Cllll•F ( '0~11'1 \INTS (( {)
Q /8 / ,
t
11~•. r1 /l ' Nll · ,~JJ

1,PHlt'H Male
~;
1101\

w~-~r~ :
/ /j

72 IIF.l<,HT ·

l'AS'I MtmlCAL HISTORY (P'\-HIJ:

N (} /-/I() - 1-1 TN I l>/Yl I - , B

c; ('\IEOIC \TIO:\) HISTOR\ : FAI\IILY IIISTORY: N 8

N v H/ o - /YJedr'ca-kon SURGICAL HISTORY: {\Jc,n~

SOCIAL & occUPA TIONAL HISTORY : l (> le'

J PERSO'.\'AL HABfTS: Diet:

ADDJCTIO!\'S-Dl 'RATION Smoking: - Alcohol: - Any other:

ALLERGIES:

GE:'\"ERAL EXAMINATION: P-1-C-C-L-E: Pallor: Yes / ~ Ictcrus/Jaundice: Yes/~ Cyanosis: Yes/~

Clubbing: Yes ll'e--- Lymphadenopathy: Yes / ~ Edema: Yes/ ~

oo D5
~ V

VITALS DI 02 D4 D6 D7 D8 D9 D10 Dll D12 D13 D14 D15

BP<mmHg)
PR / Min "1fJ t "ft/I 18- 82- 88 I
RR / Min /Bl- 291- ?9 I Jqj -
Temp. (0 C) IJ!r -
Fluid Intake (ml)
Fluid Output(ml)
HEENT IJIJI
CVS
RS
GIT
GUT
EXT U WNi
CNS No Mun ,r,un SoLJ nd.
Others
 ) ) ) ) 'I ) ) )
) ) ) )
LABOR.ATORY INVESTIGATION-.: ) )
Qt'.,M_ATOLOGy
) ) ) ) ---- ------------
I - ) ~ ~
, , ) )
(MaJeU4.3-5.9x1()8/µ I 2 tlPm PIIOflU; I 2 tJ
)J •-,
f RBC·-~- · · -rn ncv L _: l 2 ,."
=___ I KlDNEYr,\NEL fo;,LPATIENT PROGRESS
~ ) )
RBC <fem> 3.>5.0•106/µl.
~--- I lrPn •u--.., .,,~,..,~
1A.A7 mn/nl TntoLr• - - --'-"

Hct(Male1 OUN <200 IIIQIOL

39%-49% 8--20 mg/dl
Crcat1nine TGs(l·J
Hct(Fem) 0.6-1.2 mg/dl <150 mg/dl
33%-43%
Unc acid lDL 1 70- 160 mgtdl. l
Hb(Male) 14-18 g/dl <7 mg/dl
Hb(Fem)
r;.g• eGFR I IDL I 40 mg/dl
12-16 gldl 90--120 ml/min
MCV Albumin LIVER Fl lNCTION TEST
76--_1__00 IK!\3 3.3--4.8 g/dl
~._g Globulin 23--3.5 o/rll AST (SGOT) I 0-35 urnfS/L
- r• ,"lD,O Sod~
MCHc J 33--37 l.~1',0I Sodium 1135-145mEq
- a·-- tLfJ"f-ALP
iALT(SGPT) 30-120urnts/l
0-35urnts/L f'l,•,.~1...l._.
[i /BU Pef)a-nl-c Nonowf J
- on-
~~-----.1-:::27:;--3;:-:3· --
- g/dl 30 ,O I ~
ESR(Male) 0-20 mmhl Potassium 3.5-5 mt:q,L
&::i
Ji:, •o GGT 0-70 urnts/L
I" I
ESR(Fem)
=. Chloride . --- - .
95-105 mEq/L
0-30 mm/h
Calcium-total 81hrub111-total O1-1 mg/dl
WBC 4-11x103/µL 8.5-10.5 mg/dl
Alk phosphatase 30-120 U/L BI h ru b111-d1rect 0-0.2 mg/dl
Neutropbils 40%-70%
3:J:ij_. Phosphorous 2.5-4.5 mg/dl
CARDIAC BIOMARKERS
Lymphocytes 20%-40% CK-MB 10
~oi Bicarbonate 5-25 IU/L
Monocytes 22-29 mEq/L
0%-11% ,.Tnl 0 01-0 C4ng/ml
Eosinoph1ls
..n·r. URINE ANALYSIS DISCHARGE \.IEDICA TIO'JS
0%~% Color I lomocysteme 14 6-15 µmol ,L Medicines
JJ_.'lL Yellow/ amber 0,,.., J Rt. frq J Dur
B~h1ls 0%-3% _Jj'f_ LOH I 140-200 UIL
Spec gravity 1.002 to 1.030 i I
PLTCount 150-450•10'/µL MISCELLANEOUS
pH 4.5-8
Iron 60-180 n1cg/L TSH 2-10µU/ml T. flrnoxiclaue_ lt$5 en, Bbl
Protein 30 to 130 mg/day -
BLOOD GLUCOSE n 5.4-11 .5 µg/dl
RBCs S6 - T A €.hodol J f : I ! D TM
FBS 70-99 mg/dl P Lipase 0-160 urnts/L
WBC S5
PPBS PSA 0-4 ng/ml T. A to Z I lo loo
<160 mgtdl Sugar Negative
RBS <160 mg/dl fq_~/. Casts Nil -
HgbAlc <4-5.6% RADIOLOGY/ BIOPSY
Crystals Nil T pan D !""1 o CD
V,~~lf\'l,
-_
FINAL DIAGNOSIS:
L1'tJDma - Back
MEDICATION CHART FOLLO\\ l 'P: [J{fo, 1 rlt1u~
SN Drug Brand Name Generic Name Indication I I I I I J
Dose Route Freq. I 2 J ~ 5 6 7 8 9 I
I- JLL'- \/" \../' \../ \,/ v 't.--
,:.{wp l~r~1i;,' W~o?l I L1n±ib,n+frr lo 95 ti ~
rlnur,/nn,r J)r,'rf {N ~ /JLl)J \./' L,-- 1.,- v-
\...-"' '- -
!J- IT. '7e_1-11,d,!1 ¥ + Bceclo
l!;~nhnnPn- Ii, oa ~
1,An; Rf)[t'eve Joom. I r

.'? • IL !JOO t/ f'J Cia~lr/c 11/omy

I 1
tJonloo,/oin le I ,L $__erulinn
II
'l- rr. Ii .:!.Lu. I ~ 1:n: ~3:IJ IJ-11
mu 1t,·,,Jom,O I~'.~f't:l,ni
~-c~~ I I

Name & Sign. of Student. -~ htor: ~ ,

s;• -~~s~ ~
~.!{ ,
 INTEG RAL UNIVERSITY
DEPARTM ENT OF PHARM AC Y PRAC TICE
FA C ULTY OF PHARM ACY, LUCKN OW.

PATIENT
r.::-- NAMt,;..QXl llf Drv.r
---.k
-
i- M,• · ,1:, Ytor.
t
illll;lil.f'8.Qf1l.t: fQBM (Cl.GBKt l-llPl

<~.NOE1t
7r-
ll' No , JL?.? 1 o n 1.11,N 11 ,.)l,,,.7
,,.,,w/t"
oo A•
w•:m11T1 t, /..r
1,00, t;/it ~ 1
HE1<.1rr,
A t>o, ,.'Jlirt(•(n1av ;:7t
- -
REASO NS FOR ADMI .S/.ION/ ci"ii1 I• CO l\ll 'LAINfS (C T ) :
lr,~/n:U, t tJrr'rf//y /1~r/NnNl,.. {,ri'~'/5
/J,1,1'' .'17 '-"l•'f''C l'f>lt11nr-n '<!6r/r, r ~ PM
S-.T-0-lt_Y_(_ _ H_):_ _ _ _ _ _ _7
- A_S_T_I\_JE
- , . , . _ - - ,P A _L _H_I
- •D_I_C_
"'I IIS! OR\ ' OF P~ESEN T IL LN ESS f HPl):- - - - - - . . q
,'"{ ',,~ /' r,.~, '°h t,'1.rr/ Ct'mflctrnlf_. n/ Iii c r uf!Msg nl:_. NIYTle..
~e l.artd/J r.n l?6'r!&n~n on! .~he r,{r1J/5 romfft:> rnl~;
IJ O . .'r A C ,r 1 - t(tJ
FAMILY HISTOR Y : N /.';
DR UG (M E DICATI ON) IIISTO lff:

SURG:C AL HISTOR Y: ND
None
SOCIAL & OCCUP ATIONA L IIISTOR Y: l3 €."

- PERSONAL HABITS : met:

Alco!:ol: Any other:
ADDICTIONS-DURA TI ON Sa:oUn g:

ALLER GIES: No
I PHYSIC AL EXAJ\fl NAT:ON S: S.:,1:;01·iu111: Comc i~ Drowsy / Comatose
..>

I
lctcrus/ Jaundic e: Yes/ N~ Cvanos is: Yes/ No,..-
.
/ GE\"ER AL EXAJ\H NAT10i\ ': P-I-C-C -L-E: i'allor: Yes/~
Clubbin g: Yes /No L:,·,'llph adenopa thy: Y cs / N_2... Etlema: Yes / No
~

D6 D7 D8 D9 010 Ull D12 D13 D14 D15

VITALS D4 DS
BP(mm Hg)
PR/ Min
RR / Min Lf'tl P bl
Temp. (OC)
Fluid Intake (ml)
fluid Output(ml)
HEENT
CVS
RS
GIT
GUT
EXT

CHOl£LLTHIIJ$1$ t. OIPo NIC CHo t€CY S7I7 IJ 9

~
 r r r PATI

( r r r r -
r r r r 1 2~
LIPI DP~ ILE
r r r (
y JNVESTIGA TIO NS KIDNEY PANEL -
- I 2
___ ;- <200 mg/dl
Total-C::.::_ _
-
LABORATOR - 2 18-47 mgldl TGs (F) ~ mg/dl
-
----W: MATO LOGY _!__ Urea -
_.;:. ..:... --- 70-160 mg/dL
RBC(Male) 4.3-5.9•106/µl.
- BUN
8-20 mgldl
LDL -
-
RBC(Fem)
Hct(Male)
3.5-5 0•106/µl.
39%--49%
- Creatmme
Uncac1d
0.6-1.2 mg/dl
<7 mg/dl
HVL ~mg/ dl
LIVER FUNC.!!.ON TEST
-
33%--43% 90-120 mVmm AST (SGOT) o-35 units/l
Hct(Fem) eGFR
3..3--4.8g/dl 0-35 units/l.
Hb(Male) 14-18 gidl Albumin ALT(SGPT)
12-16g/dl ' 2.3--3.5 g/dl 30-120 units/L
llb(Fem) Globulin ALP
76-100µm 3 135-145 mEq/L 0-70 units/l.
MCV Sodium GGT
0.1-1 mg/dl
27 33 pQ 3.5-5 mEq,'L 9
MCH Po1Js,1um 13ilirubia-total
33-3~ gl._:.. 95-105 mEq1. 0-0.2 mg/dl
MCIIC Ci1l"nc, Bihrubin-dircct 10
::i-2c r:-"1"' l 8.5-10.5 mg/dl CARDIAC HI0'.\1ARKERS
CSR(Ma!e)
0-3~ r:-~.r.1
Calcium-total
DISC HAR GE
MED ICA TIO NS Dur
ESR(Fem/ Al, pl,ospllJtas~ 30-120U/L 5-25 IU/L Rt. Frq
t:~ j,,. ~~ ,,., .. CK-Ml3 Dose
\1.l~C Phosr!1orous 2.5-4.5 mg/dL
cTnl
0.01-0 04ng/ml Medicines
Neutrophils lJ%,--fC~ I Bicarbonate 22-29 mEq/L 4.6-!SµmoUL
I Homocysteme
Lymp~OC)1CS 20~,...(J'.
0%-11~,
URIXE ANALYSIS
LOH 140-200 U/L Jab .(}jlu.rn 500 B!J
MonOC)lCS Yellow/ amber
Eosmopluls Oo/o-8%
Color
Spec gra\1ty 1.002 to 1.030
TSH
MISCELLANEOUS
2 10µ\J/ml
Tat. Tnyplomfl-t> - B!J
0~%
Basophils
PLTCount 150-450i<10'//IL ' ' pH 4.5-8
T4 5.4-11.5 µgldl 'o-L . fome~I-, n - l - ()1,
Protein 30 to 130 mg/day
Iron 60-180mc.g'L
RBCs S6
P. Liplllle 0-1601.11its/L
traA. Refo/01 Fo'hle Sb
BLOOD GLUCOSE 0-4 ng/ml
Sy f · J; t1'f~oloc Jei m I IC
PSA
WBC S5
FBS 7M9mgd1.
Sugar Negative
PPBS <160mg/dl ()/)
Nff RADI OLO GY/ BIOPSY Tab- fl ·to 7
RBS <160mg/ti. Casts
Crystals Ni Oe.r,que,-+ N~ 1 Aq . . . Re~ c~ "(
HgbAlc <4-5.6%

t f ITH I fl SIS CHJ?oNfC CHOffCV'l.r.ITIS FOLLOW UP:. _ _ __':1-_~....,.,,,.i:--g_ _

N.-=-/!f~vz.
l\fED ICAT I ONC HA R T
T
I FlNAL DIAGNOSIS: CHO l C

},"req. 7 8 9 o = .-..
Indication Dose Routl'
SN Drug Brand Name

V v ✓

Name & Sign. of Student:

 INTEGRAL UNIVERSITY
FACULTY OF PHARMACY
LUCKNOW
Patient Profile form
(Plwm 11. lntP.m,;h,p)
rim,~
~ ' ' 11 .,
... rnaz,a. - l ,r,o ')l,(,nl IHrt ,,;11 f T110, :Jof,t') q•3 110n t; 11 .Q'
L:!'':....-1.iz.Jeli,,u.>L8a:nnbnnk1 "·'
IU ,.,o,, I ok \ll'llSSl(l'\/ ( llfl l ( n,,r, "", . . ,, ' )
9.N'f 1'· 1
'
111
« I rtri l \H ''·'" 'j 'J "'rJ HH<,111_ _
• --1
Pam /n ttff<!'l llhrl()m('n >< '),non II,
Bwmrnl ~ /llt'c.fu,,d,on,.. 1
1 f'layc;
1-- __ i fc. e"1 ()n /off x a· tt rf~P:.
;r•;~~~ <~~~if;S~;);f. '?t;);'l,7~)i,/,$ of-/ ne ffl<n/h., p.'°'J '\HDH ,\L IIISIOIH IP"HI):
'f!.hiom~n 5 rnce ?, rnonlh anrl. llhf' a&o comp ft,,,/~ No Med,'coe / t,slo 11J
'hl'ltn 11,c.la>11/-t°rJn ;( Feue•1 on /of r 1/ do I g
ORIG 1-'DIC\TI0'\)IIIS T0R): F\i\111.YIIIST0RY : N S

No H/o Merl/co!tm SURGICAL IIIST0RY: NI s

SOCIAL & OCCUPATIONAL HISTORY: LC u._1

PERSO'\'.AL HABrTS: Diet: NtJn - Ve

ADDICTIO'\S-Dl'R .\. TION Smoking: Alcohol: Any other:
ALLERc1Es: None..
j PHYSICAL EXA!\IINA TIONS: Sensorium: O?n?1s /Drowsy/ Comatose

GE"\ERAL EXA..'\tINATIOJ\: P-J-f'-C-L-E: Pallor: Yes /,Jj.,e-- lcterus/Jaundice: Yes/~ Cyanosis: \'es/~
Clubbing: Yes~ Lymphadenopath y: Yes/~ Edema: Yes/~

\'lTALS DI D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15

BP(mmHg)

'r:18 u
-
l PR Min
/ RR ~in ~o
/ Temp (°C) fJ IF
! Fluid Intake (ml)
/
fluid Output(ml)

HEENT
CVS
RS
GIT
G(Jl

EX'f
CNS
Others
I I
PROVJSfONAL DIAGNOSIS:
Chole/il/,/tul~ ?
 ) ) ) ) ) ) ) ) )
RATORY INVESTIGATIONS ) ) } ) )
Ht:MATOLOGY t 2 ' ) ; ")?'JJ
KIDNEY l'.\NEI. II 12 P,H JENT PROGRESS
4.3-5.9x1()6/µL Urea Lll'JI> l'IWFILE
18-47 mg/dl Day T
3.5-5.0x1()6/µL Total-( · I<200 mg/dl ~- Pro/!.,!'!_~s - _ --=1
BUN 8-20 mg/dl ~ r
Hct(Mate) I 39%-49% Creatinme His(Fi <150mg/dl
0.6-1.2 mg/dl 2
Hct (Fem) I 33%-43% Unc acid
u~•-~~cm
<?m
LOI. 70 160mg.df
Ff/
1
-f-- - - - - --------..../
/
Hb(Male) .,,,
...14-18•~ g/dl I IC(.WR
~~ m~~dl.
I I I
1
j I IDL 40 mg/dl _- - - - - - - - - - - - . . . . ; /
90-120 m11m1n 1 1
Hb(Fem) • , uvi,,n. Ft NcnoN TEsT ~- r
12-16 g/dl B,3'1" Albumm 3.3-4.8 g/dl I\ST(SGOT) ---1
MCV I 0-35 urnts/L fOl' , lJ
7~100µm3 Globulm 2.3-3 5 g/dl '
!\LT (SGPT1 0-35 urnts/L !IS o
MCH 27-33pg Sodium 135-145 mEq/L ALP 30-120 urnts/L
MCHC 3l-37 g/dl Potassium 3.5·5 mEq/L GGT 0-70 urnts/L
ESR (Male) 0-20 mm/h Chloride 95-105 mEq/L Bil1rub11Hotal 01-1 mg/dl
ESR(Fem) 0-30 mm/h Calcium-total 8.5-10.5 mg/dl B1hrub111-d1rec1 I 0-0 2 mg/dl
WBC 4-11 K103/µL Alk phosphatase 30-120 U/L CARDIAC BIOMARKERS 10
Neutrophils 40%-70% Phosphorous 2.5-4.5 mg/dl CK-MB S-25 IUIL
Lymphocytes 20%--40% Bicarbonate 22-29 mEq/L cTnl 0 01-0 04ng/ml
DISCHARGE MEDIC\TJO'iS
Medicines Or,~ Rt. rr 1 . Our
Monocytes 0%-11% URINE ANALYSIS Homocys1e111e j 4.6-1511mollL
Eosinoph1ls 0%--8% Color Yellow/ amber LOH j 140-200 U/L
Spec gravity 1.002 to 1.030 MISCELLANEOUS
T Sornet+rr~ L
Basopllils 0%-3%
150-450•103/µL pH 4.5-8 TSH 2-10µU/ml T, Replet fo~f j;
PLTCount t. 60
Protein 30 lo 130 mg/day T4 5.4-11 .5 µg/dl
Iron 60-180 mcg/L 1
RBCs S6 p Lipase 0-160 urnts/L Sttp Dtfohab ·
BLOOD GLUCOSE
S5 PSA 0-4 ng/ml
70-99 mg/dl WBC
FBS
<160 mg/dl Sugar Negative
PPBS
93 ,o Casts Nil
RBS <160 mg/dl
Crystals Nil
HgbAlc <4-5.6%
FOLLO\.\ l P: _ _ _ __ _ _ __
FINAL DIAGNOSIS:
I -;;
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MEDICATION CHART
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L I Name & Sign. of Student:

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 INTEGRAL UNIVERSITY
FACULTY OF PHARMACY
LUCKNOW
Patient Profile Form

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FAMILY IUSTORY: Nt'

suRGICAL H1sT0Rv: None,

No H/ o /VJec!t'calt'tm soc1AL & occuPAn oNAL msToRv: Low

PERSONA L HABITS: --
.-\DDICTJO NS-DlR<\ TION Smoking: ~
ALLERGIE S: None
PHYSICAL EXAMlNA TIONS: Sensorium: Cons . us/ Dmwsy 1 Comatose

lcterus/Jau ndice: Yes/~ Cyanosis: Yes / ~

GE.NERAL EXAJ\IINA TION: P-1-C-C-L -E: Pallor: Yes/~
Clubbing: Yes~ Lymphade nopathy: Yes / ~ Edema: Yes/~

D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 , D13 D14 l D15 l

\'lTALS DI
BP(mmHg )
PR/Min
RR/Min UJ/m Golm /8/m /0/m
Temp. (°C)
Fluid Intake (ml)
Fluid Output(ml )

HEf:NT }J(J/
CVS I P. I I ,, IPl'li
RS
Gff
GUT
EXT I JIDI\
CNS
Others
.,
.LI
 'ORY INVESTIGATIONS ) ) ) ~ -- -
J ) ·"~
OLOGV 11 12 ) j j j j j j J )
KIDNE \' PANEL ) j
CMafe) r4.3-S,9lC1QG/µL 2 I
Urea 1.1r10 Pr<m,,.,..
--- P,\Tl£'VT PROGRESS
RBc (Fem) 3.5-5.0x 100/µL 18-47 mg/dL l_l I2
BUN l otal-C <200 mg/dl ~ay~f - --- P--;:og,-e s-~- ----- .
Hct(Ma le) 8-20 mg/dl
39%-49% 'I Gs fl· 1 l
Creatm1ne <150 mg/dl
l-lct (Fem) 0.6-1.2 mg/dl IO,
33%-43% LDL 70 Ir,o mg,cll
Unc acid <7 mg/dl !- -~
Hb(Ma le) 14-18 g/dl IIDL
eGFR 40 mg/dl
Hb(Fem ) 90-120 ml/mm .J
12-16 g/dl
-Album111 3 3-4.8 g/dl
LIVER FI INCTION HST -L r /f ,. r - .
, . u ,nfl/ ,~ •
MCV 76-100µm3 ASTfSGOT) umts/1.
G-35 umts/1.
G-35
Globulm L,,J-,J
2.3-3.5 ,O 910L
g/dl ALT (SGPT) --- .
-
~MCH ·~~--v.:;.-
I. 21--3 . ;-;;• ALT(SGPT) G-35 umts/1.ts/l I
~135-14
135-145 5mEq/L
mEq/L ALP 3G-120uni
27--33pg Sodium nJ::n/1 •-
ALP
~--
MCHC
··- 33-37
r,i-,_-,-, gi __
-•J• 3G-120 umts/1.
3.5-5 mEq/L GG1
ESR(M ale) 0-20mmn, G-70 units/I.
Chlonde 95-105 mEq/L
ESR(Fe m) B1ltrub111-total 01-1 mg/dl
0-30mm/h Calcium-total 8.5-10.5 mg/dl B1ltrubm-d1rec1 G-0 2 mg/dl
WBC 4-11 x103/µL Alk phosphatase 30-120 U/L C' ARDIAC BIOMARKERS 10
Neutrophils 40%-70% Phosphorous 2.5-4.5 mg/dl
- CK-MB S-25 IU 1L
Lymphocytes 20%-40% Bicarbo nate 122-29 mEq/L cTnl 0 01-0 04ng/ml DISCH..\RG E \.IEDIC.-\ flO'iS
0,..., R, 1
'1l edicines Fr, Ou
Monocytes 0%-11% URINE ANALYSIS 1-Iomocyste111e 4 6-15 µ11101/L
Eosinoph1ls 0%-8% Color Yellow/ amber LDH 140-200 U/L
Basophils 0%-3% Spec gravity 1.002 to 1.030 MISCELLANEOUS ~" 3"
C , ,, -~ ~ Dt{ .)I """' l.J
pH 4.5-8 TSH 2-10 µU/ml
T •4rnr::.,,'i'l'"
PLTCo unt 150-450• 103/µL
Protem 30 to 130 mg/day T4 5.4-11 .5 µg/dl ,, ,..,
T, 7.e,'firxf.,I 1/ " ' "' Cv· w'
Iron 60-180 mcg/L
RBCs :56 p Lipase G-160 urnts/L
BLOO D GLUCOSE
:55 PSA 0-4 ng/ml Co.p Por.-l cf tJcci a C'.,
70-99 mg/dl WBC
FBS
Sugar Negative --
PPBS <160 mg/dl /. nn / C ,.- ' ,v
"' ·""
Nil
RADIOLOGY I BIOPSY
Casts
RBS <160 mg/dl
Crystals Nil
HgbAl c <4-5.6%
fOLLO \\ t'P:._ _ _ _ _ _ _ __
NOSIS [~g/-- fJn -Me bock ;;
5
MEDI CATI ON CHART Route I Freq.
I Dose I Ro I I I 2 I 3 I ~I
Generi c Name
I Indication I.,~ ,. \. I'-
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Drug Brand Name

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 INTE GRA L UNIV ERSI TY
FACUL TY OF PHAR MACY
LUCK NOW

Patien t Profile Form

(Pharm D. lntr.rns h,p)
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PERSO X\L HABIT S:

-\DDIC TIO:\S -Dl 'RATIO N

I ALLER G1Es, No H/ 0 !/ f(!/1

9
j PHYSICAL EXA\U NA TIONS : Sensori um: C:_in ~ /Drow sy/ Comato
v
se

Yes /~ lcterus /Jaund ice: Yes /~ Cyanosis: Yes / ~ -

GE:\E R,U. EXAM L"\'ATI ON: P-1-C-C-L-E: Pallor:
Clubbi ng: Yes ~ Lymph adenop athy: Yes /~ Edema : \' es / ~

D6 D7 D8 D9 D10 Dl 1 D12 D13 D14 D15

\1TAL S DI D2 D3 D4 D5
130
BP(mm Hg) !9 t/ rr rnH 1
PR / Mio Bl/ 1 mi, {/'-'
RR. t Min 18 I ~,il - Ir, m ll(' () fl ri ti I hl'-i /1(' !/ ~- orl.n1 ri y
t,,r.lJ,,,.,J "'-. ei r:, / v--
'femp . (CC) QB·~ I
fluid Intake (ml)
fluid Output(ml)
- H,'q 1 St r:,QJi 'e v~t - Ci n f,,( '/e~t
I , ,
T,n ~I ltn " !.,-it T ' I\,-. +,
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HEENT NI, r, I o/nOI

CVS NI\ m,~ 0

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RS
GJT
GlJT
EXT
CNS
\ \ \ \
O~ers
DIAGNOSIS:
 ___ • ""• • ., - , ~- -, f<IDNti.:l' . ...
"EV PANEL I 2 l.ll'ID l'ROFll,F, J' J2 j , -
., ,,~
2 I
Urea
BUN M
I 15-47
18-47 mg/dL
JI a.201
UPID PROFILE
·1otal-C
·1otal-C J<200 mg/rJL
<200 mg/rJL J J2 /' ' Day
PATIENT PROGRESS
....• F ~il.

'"' 11 ~" ma/dl ·tTr:.•

t -. .,.;, l I
n. ... , rr. J•, I ·- · .. '" ' , , I
, -·- ·- - .. tlUN """ 1 <150mgidl - < [7/f'V
I S.20mg/dl ' •,, UJO/J tcflC /J1ef: /
~ Creaunine <iSO mgJOL 1v' _ - · 1 - , ·
3.9°t...Aao,_ I- I.L 111\jlUL
0.0• 2 I fJ n o
liltl- ~ r--
· 1-1.2 rng/dl O. 3l LDL
LDL 70- 160 111g. tll. 2
Urtc acid 70- 160111g tl l. -
1 10 1 1
1<7 mo/dl IIDL 7 J
acid <7m~w "'--''· 40 mgldl
40mgldl , " 1( loCi'tkt> !
eGFR I 90-12c / 4 r,111" ,..1
t.ttnlM<tl'P.\ u- ~ , .., LIVERFl!NCTION TEST "•
FR 90-120ml/min -- I rnJ., WtOUtn
LIVER FUNCTION H ST 4
Albunun H....tBa/dl
:::),ii I I /-\,) I I c> ltl JI l I rL..1 t; ' ,n,lo /1 I , .. " I ;
lbunun l 3.3-4.R
..-.1 l 1• ~ (_SGOTJ 0-35 umts/L
...._.&\,IU\.llllt
~
~ldl
' ' ALT
' .. GPT1
, .,fS""' " , ttn l'Tf /
l 71-15 ,.,
, . _ 7&-fllO ""' GrobuHn
Sodium , ,-,,., ~ " umts/L
0-35 ""'~L _/ -6 , ",,
27_'""'"" Sodmm 11i;.1.ismEq..
I 13~14.<•e,•. ,ALP,, ,0.120~,wt I. · ' ' ·; I
.• -~CH i'·, 30-120 umts/L .lY. 1./ .o
.o I,- lo 10 '
. . .
Potassium I 15.5 :: ::-:- I .,..., 1~1L I 1 1 R7 l •C ·'
-- -- 'otassrnm mFn/1
3.5-5 mEq/L GOT 0-70u ur11 umts/L I JfJ'C T 1 ' .. 1
- 11
I -uco· O. 'L..J. , 1 n ""--.A I Chlonde
:mde 95-105 mEQIL
l 95.1os ~" ..~•~ii:-!::!~! 81-1 ;,,9/d~
B1l1wbin-total 0 H mg/dl 8
t ~ (.l:'em) IJ-30 lnmlh Calcium-total I 8.5-10.5 mg/di mQ.I__ 0 ·'·-· L . .. :'.:.- • • : : . : .. ,~; ~L
-
B1l1rt1b111-direct :0-0.2 mg/dl ?
~--· • • ·-· · Alk phosphatase
hosphatase 30-120 U/L BIOMARKERS
CARDIAC BIOMARKERS
CARDIAC -rn
I'!
r At; mnUI .11 ,- - , " ~., • • - · • •• .. ...
10
-
40%- .7(}11/.,. I I f Dl,M.I,......
Phosphorous I ~ t;
L • ..r-t . V 111~1\JL. CK-i\.iB 5-2) IUIL
Lymplk>cytes I 20o/o-40% Bicarbonate 22-29 mEq/L cTn.1 DfSCHr\RGE \1EDJC.\ TfO:'iS
0 01-0 04ng ml
.M~nocytes I 0%-11% URINE ANALYSIS Homocysteme
Medicines Oo.-.e I RL j f n1 ! Dor
4.6-1 5111110J1L
I
Eo.sinoph1ls I 0%-8% Color I i ,
Yellow/ amber LOH 140-200 U/L ,- I"' (r:~f,.-f.Jfr)
, . le . ~
BasopMs I 0%-3% Spec. gravity 1.002 to 1.030 I\IJSCELLANEOUS .t
PU Count I 150-450•1@/µt. pH 4.5-8 TSH 2-10 µU/ml -.-
! . /)(11; ,.,
~'./')1)''"1I1 ": if"c , I!7· I
1ron I 60-180 mcg/L Protein 30 to 130 mg/day T4 ,,,~,;\';· 5.4-11 .5 µgldl
P. L1Hase ' 0-160 umts/L r T , ,, . O:) ; ,--4 F.5 ctO..J ~
BLOOD GLUCOSE RBCs S6 T, I 6-C
WBC S5 PSA , 0-4 ng/ml
FBS 70-99 mg/dl
PPBS <160 mgfdl Sugar Negative gyP l'u
Casts Nil RADIOLOGY/ BIOPSY
RBS <160 mg/dl
HgbAlc <4-5.6% ("/ti.Of: ICrystals I Nil
.. 0fo mt: Qil L°v FOLLO\\ l P:_•~:_r_•..,~_,_......,___ _;;_..1---
FINAL DIAGNOSIS: - Grna
s :
-' - I -
;::; - - -
- '-- Jt
MEDICATION CHART 2 I J 5 6

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Sign. o{ l'~t·n•ptor:
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aut• & s ~-·f student:
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