PATIENT CASE RECORD

NAME OF THE CASE: DATE:

PATIENT DETAILS:
Name: Age: Gender:
Weight: Height: BMI: I.P.No:
Department: Date of admission: Date of discharge:

CHIEF COMPLAINTS:

HISTORY OF PRESENTING ILLNESS (HOPI):

PAST MEDICAL HISTORY: PAST MEDICATION HISTORY:

PERSONAL HISTORY: ALLERGIC HISTORY:

Diet: Appetite:
Sleep: Micturition:
Bowel and Bladder:
Social Habits: Smoking Alcohol
Pan Illicit Drugs
Food Habits: Vegetarian Non- Veg
FAMILY HISTORY: MENSTRUAL HISTORY:

DEPARTMENT OF PHARMACY PRACTICE (PHARM. D)

MARRI LAXMAN REDDY INSTITUTE OF PHARMACY
 PATIENT CASE RECORD

OBSTETRIC HISTORY: GYNAECOLOGICAL HISTORY:

IMMUNIZATION HISTORY: OTHER HISTORIES IF ANY:

DIAGNOSTIC APPROACHES:
GENERAL PHYSICAL EXAMINATION:
Sensorium: Conscious/ Drowsy / Comatose.
Pallor: Yes/ No Jaundice: Yes/ No Cyanosis: Yes/ No Edema: Yes/ No
Clubbing: Yes/ No Icterus: Yes/No
Hair: Skin: Nails:
Others (if any):

VITAL SIGNS:
DATE
TEMPERATURE
BLOOD
PRESSURE
PULSE RATE
RESPIRATORY
RATE
Spo2

SYSTEMIC EXAMINATION:

DEPARTMENT OF PHARMACY PRACTICE (PHARM. D)

MARRI LAXMAN REDDY INSTITUTE OF PHARMACY
 PATIENT CASE RECORD

LABORATORY INVESTIGATIONS
Observed Reference Observed Reference
Test Test
value Range value Range
COMPLETE BLOOD PICTURE: 50–150 mcg/dL
(M)14–17.5 g/dL Zinc (7.7–23
Haemoglobin
(F)12.3–15.3 g/dL mmol/L)
(M): 42–50% 70–140 mcg/dL
Haematocrit Copper
(F): 36–45% (11–22mmol/L)
(M) 4.5–5.9 × 1012 URINE ANALYSIS:
cells/L Volume
RBC count
(F) 4.1–5.1 × 1012 Colour Pale yellow
cells/L Appearance Clear
Reticulocytes 0.005–0.025 Specific gravity 1.016–1.022
RDW 0.115–0.145 PH 4.6-8.0
PCV 36.0-46.0 % Protein Negative
MCV 76.0-96.0 fl 0.3–1 Ehrlich
Urobilinogen
MCHC 30.0-35.0 % unit
5000-11000 Bilirubin Negative
WBC count
cells/mm3 Blood and Hb Negative
Neutrophils 40.0-75.0 % Urine glucose Negative
Lymphocytes 20.0-45.0 % Pus cells 0-2/ hpf
Eosinophils 1.0-6.0 % RBC 0-3/ hpf
Monocytes 2.0-10.0 % Epithelial cells 2-3/ hpf
Basophils 0.01-0.1 % Crystals
Platelets 150-400 thou/mm3 Hyaline/Cellular
MPV 6.8–10 fL Casts /Granular and
Total count 4.0-11.0 thou/mm3 Waxy
ESR 1.0-15.0 mm/hr Ketones Negative
SERUM ELECTROLYTES: Nitrite Negative
135–145 mEq/L Leucocyte
Negative
Sodium (135–145 esterase
mmol/L) Electrolytes
3.8–5.0 mEq/L LIVER FUNCTION TESTS:
Potassium
(3.8–5.0 mmol/L) Total Bilirubin 0.3–1.3 mg/dL
9.2–11 mg/dL Indirect bilirubin 0.2–0.9 mg/dL
Calcium
(2.3–2.8 mmol/L) Direct Bilirubin 0.1–0.4 mg/dL
95–103 mEq/L Total protein 6.4-8.2gm/dl
Chloride
(95–103 mmol/L) S. ALB 3.4-5.0gm/dl
1.7–2.4 mg/dL S. GLOB
Magnesium (0.7–0.99 Albumin to
mmol/L) 1.0-2.1
globulin ratio
2.3–4.7 mg/dL SGOT/AST 15.0-37.0IU/L
Phosphorous (0.74–1.52 SGPT/ALT 30.0-65.0IU/L
mmol/L) ALP 33–96 units/L
Manganese 4–15 μg/L GGT 9–58 units/L
DEPARTMENT OF PHARMACY PRACTICE (PHARM. D)
MARRI LAXMAN REDDY INSTITUTE OF PHARMACY
 PATIENT CASE RECORD

Test Observed value Reference Range X-RAY:

LIPID PROFILE TEST:
<200mg/dl-
desirable
Total
200-239mg/dl-
cholesterol
borderline
>240mg/dl-high USG:
HDLC 35.0-70.0mg/dl
LDL <100mg/dl
VLDL <40mg/dl
Cholesterol:
0.0-5.0
HDL ratio
Triglycerides <150 mg/dL
BLOOD GLUCOSE TESTS:
Random blood
110-180mg/dl
sugar
Fasting blood
70-110mg/dl
sugar
Postprandial ECG:
110-160mg/dl
blood sugar
HbA1C 4–5.6%
RENAL FUNCTION TESTS:
Serum
0.6-1.2 mg/dl ECHO:
creatinine
Serum urea 3-8 mg/dl
Blood urea
8-23 mg/dl
nitrogen
Uric acid 2.6-7.2 mg/dl
THYROID FUNCTION TESTS:
Total Sr. T3 80–200 ng/dL
Serum T3
25–38% OTHER TESTS (if any):
Resin Uptake
Total Sr T4 5.5–12.5 mcg/dL
Free T4 0.9–2.3 ng/dL
Free T4 Index 1–4 units
0.5–5.0
TSH
milliunits/L
Parathyroid
10-65 pg/ml
hormone
Thyroglobulin >55 ng/ml
12-30
TBG
microgram/dl
Antithyroid
Antibodies

DEPARTMENT OF PHARMACY PRACTICE (PHARM. D)

MARRI LAXMAN REDDY INSTITUTE OF PHARMACY
 PATIENT CASE RECORD

FINAL DIAGNOSIS:
PRESCRIPTION CHART:
S. DRUG GENERIC
DOSE FREQ ROA DAYS PRESCRIBED INDICATION
NO PRESCRIBED NAME

DEPARTMENT OF PHARMACY PRACTICE (PHARM. D)

MARRI LAXMAN REDDY INSTITUTE OF PHARMACY