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updated pt profile form (2)

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15 views

updated pt profile form (2)

Please form

Uploaded by

time21637
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PATIENT PROFILE

PATIENT DEMOGRAPHICS:

Name: Father Name: Age:


Gender: DOB:
Weight: Height:
Bed #/ Ward #: Date of admission:
Address: Patient Contact Number:
PRESENTING COMPLAINTS/ CHIEF COMPLAINT:

HISTORY OF PRESENTING ILLNESS:

PAST COMPLAINTS/CO-MORBIDITIES /PAST MEDICAL HISTORY:

PAST MEDICATION HISTORY:

Drug Name Drug Name Dose Route Frequency Duration Purpose


Brand Name Generic Name

SOCIAL HISTORY:

Occupation: Marital status:


Pregnancy Status: Living status:
Smoking: Yes No Travelling:
If yes, packs per day? Family support:
Socio-economic status: Family History:
PHYSICAL EXAMINATION:

VITAL SIGNS:
Temperature: Blood pressure:
Respiratory rate: Pulse rate:
Heart rate:
SYSTEMIC REVIEW:
CVS: GUT:
GIT: RT:
CNS: Abdomen:
LABORTORY DATA:

HEMATOLOGICAL:
Test Value Ref Test Value Ref Test Value Ref
RBCs M 4-5.5.5/mm3 ESR M<6 mm/h
F 3.5-5.5mm3 F<10 mm/h
Hb M14 to18g/dl MCV 80-100fL
F12 to16g/dl
WBCs 5000-
10,000/mm3 MCHC 31-36g/L

Platelets 150,00 to
350,00/mL
BIOCHEMICAL:
Test Value Ref Test Value Ref Test Value Ref
Na 136-145mmol/L Alkphos 54-369U/L Protein 6-8g/dL
K 3.5-5.0mmol/L Creatinine 0.6-1.2mg/dl Urea 3.5-7.4mmol/L
Cl 96-106 mEq/L Biliribin 0.3-1.9mg/dl Uric acid 2.5 -7.5mg/dl
Cal 8.2-10.6mg/dL AST 0-35U/L T3 60-181mg/ml
Phos 2.0-4.5mEq/L ALT 3-36 U/L T4 4-12 μg/ml
BUN 7.0-25mg/dl Albumin 3-2.5g/dl TG 0-200mg/dl
Glucose 70-105mg/dL LDL <3.37mmol/L
CO2 35-45mm Hg HDL >0.9 mmol/L
MICROBIOLOGICAL:
Infectious Agent Name of Infection Infectious Agent Name of Infection

COAGULATION:
Test Value Ref Test Value Ref Test Value Ref
I.N.R 0.9-1.2 APTT 28-38 sec
P.T 09-14 sec

DIAGNOSTIC TESTS:
PROVISIONAL DIAGNOSIS:

FINAL DIAGNOSIS/IMPRESSION:

CURRENT MEDICATIONS (IN WARD)

Drug Name Drug Name Dose Route Frequency Duration Purpose


Brand Generic Starting date Stop date

FOLLOW UP:

PHARMACIST’S NOTE:

DISCHARGE MEDICATIONS/DISCHARGE INSTRUCTIONS:

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