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    Patient Profile Form

    Uploaded by

    ShaRath Km
    This document appears to be a clinical proforma used to collect patient data, including demographics, medical history, vital signs, laboratory results, diagnosis, medications, and clinical notes for patients with type 2 diabetes mellitus admitted to a tertiary care hospital in India. The proforma collects extensive longitudinal data over the course of a patient's admission to help evaluate their care and treatment outcomes. The study aims to analyze oral hypoglycemic drug utilization patterns and outcomes in patients with type 2 diabetes.

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    Patient Profile Form

    Uploaded by

    ShaRath Km
    12 views8 pages
    This document appears to be a clinical proforma used to collect patient data, including demographics, medical history, vital signs, laboratory results, diagnosis, medications, and clinical notes for patients with type 2 diabetes mellitus admitted to a tertiary care hospital in India. The proforma collects extensive longitudinal data over the course of a patient's admission to help evaluate their care and treatment outcomes. The study aims to analyze oral hypoglycemic drug utilization patterns and outcomes in patients with type 2 diabetes.

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    Clinical data patient performa

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    This document appears to be a clinical proforma used to collect patient data, including demographics, medical history, vital signs, laboratory results, diagnosis, medications, and clinical notes for patients with type 2 diabetes mellitus admitted to a tertiary care hospital in India. The proforma collects extensive longitudinal data over the course of a patient's admission to help evaluate their care and treatment outcomes. The study aims to analyze oral hypoglycemic drug utilization patterns and outcomes in patients with type 2 diabetes.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    12 views8 pages

    Patient Profile Form

    Uploaded by

    ShaRath Km
    This document appears to be a clinical proforma used to collect patient data, including demographics, medical history, vital signs, laboratory results, diagnosis, medications, and clinical notes for patients with type 2 diabetes mellitus admitted to a tertiary care hospital in India. The proforma collects extensive longitudinal data over the course of a patient's admission to help evaluate their care and treatment outcomes. The study aims to analyze oral hypoglycemic drug utilization patterns and outcomes in patients with type 2 diabetes.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 8

    A CROSS-SECTIONAL EVALUATION STUDY AND DRUG UTILISATION PATTERNS OF ORAL-

    HYPOGLYCAEMIC AGENTS IN PATIENTS WITH TYPE II DIABETES MELLITUS IN A


    TERTIARY CARE HOSPITAL

    Sarada Vilas College of Pharmacy


    Department of pharmacy practice
    &
    Apollo BGS Hospital, Mysuru.
    Date:
    Case No.
    PATIENT CLINICAL PROFORMA
    Patient Demographics:
    Name Age Sex Weight Height BMI IP. No Department DOA DOD

    Patient Medical History:


    Reasons for Admission:

    Past medical history:

    • History of HTN: Yes No


    • Co-morbidities: Yes No
    • If yes, specify

    Past medication history:

    Social history: Smoker: Y / N Alcoholic: Y / N Marital status:

    Tobacco use in any form: Y / N


    Known Allergies:

    Vitals:
    Days 1 2 3 4 5 6 7 8 Indications
    BP (120/80 mmHg)
    Pulse (60-100bpm)
    Body Temp (97-101℉)
    RR (12-20 breath/min)
    SPO2 (96-99%)
    PATIENT DATA - QUERY REPORT
    Laboratory Data:
    Hematology:
    Days 1 2 3 4 5 6 7 8 Indications
    Hb:(g/dl) M: 12-16 F:11-14
    WBC: 4,500-11,000mcL
    RBC:M:4.7-6.1
    F:4.2-5.7million cells/mcL
    Platelets:150-400 x 10⁹/L
    DLC Neutrophil (48-77) %
    PLT Eosinophil (1-4) %
    Basophil (0.5-1) %
    Lymphocyte (10-40) %
    Monocytes (2-8) %
    PCV: (M:0.46 F:0.42) %
    ESR: (M:1-13 F:1-20) mm/hr

    Biochemistry:
    Days 1 2 3 4 5 6 7 8 Indications
    FBS (60-90 mg/dl)
    RBS (90-110 mg/dl)
    PPBS (80-150 mg/dl)
    HbA1c (4-5.6%)
    Urea (7-20 mg/dl)
    Sr. Creatinine (0.84-1.21 mg/dl)
    CKMB (3-5%)

    Liver function tests:


    Days 1 2 3 4 5 6 7 8 Indications
    Total bilirubin (<1mg %)
    P.T. Time (14 sec)
    Alka. Phosphatase (84-306 U/L)
    SGPT/ALT (7-56 U/L)
    SGOT/AST (5-40 U/L)
    LDH (140-280 U/L)
    Bilirubin: Total: (0.1-1.2mg/dl)
    Direct: (<.3mg/dl)

    Renal function tests:


    Days 1 2 3 4 5 6 7 8 Indications
    eGFR (90ml /min/1.73m²)
    Urea (mg %) (15-45)
    Uric acid (mg %) F-2-5, M-2-7
    Sr Creatinine (mg %) (0.6-1.4)

    Electrolyte (mEq/L):
    Days 1 2 3 4 5 6 7 8 Indications
    Sodium (130-150)
    Potassium (3.5 – 5.8)
    Chloride (98-100)
    Bicarbonate (22-36)
    PATIENT DATA - QUERY REPORT
    Fluid Intake & Output chart:
    Days 1 2 3 4 5 6 7 8 Indications
    Intake (ml)
    Output(ml)

    Urine examination:
    Days 1 2 3 4 Days 1 2 3 4
    Color Sugar
    Bile salts WBC
    Bile pigment RBC
    Albumin Casts
    Pus cells Epithelial cells

    Lipid Profile:
    Days 1 2 3 4 5 6 7 8 Indications
    HDL (35-60mg/dl)
    LDL (130-160mg/dl)
    VLDL (2-30mg/dl)
    Triglycerides (160-200mg/dl)
    Total cholesterol (200-240mg/dl)

    Microbiology:

    Other investigation:

    Diagnosis:

    Current medication:
    Sl. Name of medication DOSE ROA FREQUENCY Days of Treatment
    No
    Brand Generic D.1 D.2 D.3 D.4 D.5 D.6 D.7 D.8

    1.

    2.

    3.

    4.

    5.

    6.

    7.

    8.
    PATIENT DATA – CLINICAL NOTES
    Clinical Notes:
    D.1 D.2

    D.3 D.4

    D.5 D.6

    D.7 D.8

    D.9 D.10

    Clinical pharmacy services provided:


    Activity Number Code Activity Number Code
    1. 3.

    2. 4.

    Discussions / Interventions made

    Student Name: Preceptor Name:

    Signature: Signature:
    PATIENT DATA – CLINICAL NOTES

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