PATIENT PROFILE FORM

DEPARTMENT OF PHARMACY PRACTICE

NARGUND COLLEGE OF PHARMACY, BANGALORE

PATIENT NAME: mr.sivaramaih HOSP. NO: DATE OF ADMISSION: 27/11/2016

02228171
DATE OF DISCHARGE: 3/12/2016
AGE: 20yrs WEIGHT: 48.9 kg HEIGHT :150 cm SEX: m

COMPLAINTS ON ADMISSION:C/O fever since 4 days

H/O vomiting – 4 times

MEDICAL HISTORY: No H/O DM,HTN

MEDICATION HISTORY: -
SOCIAL HISTORY:
FAMILY HISTORY: Not Significant
PREVIOUS ALLERGIES:-

PHYSICAL EXAMINATION: General weakness

GENERAL - PICCLE
VITAL SIGNS - B.P-110/80mm of Hg, P.R. – 88/min , Temperature- 99o F , Respiration- 18cycles/min
HEENT -
CVS - NAD
RS - NAD
GIT - NAD
GU -
EXT -
CNS - NAD

PROVISIONAL DIAGNOSIS: Malaria?

ROUTINE BIOCHEMICAL INVESTIGATIONS 27/11/2012
L
HAEMATOLOGY:
RBC : 4.6× 10ˆ6/µL RDW:12.4%
Urea: 22mg/dL (8-35mg/dl) RBS:109 mg/dl Alb: 4 g/dl: (3.5-5g/dl)
3
WBC: 4900 cells/mm Hb:13.9g/dl
S.Cr : 0.7 mg/dL (0.6-1.6mg/dl) Glob: 3g/dL (1.8-3.4g/dl) N: 57%(35-75)% MCV: 88.9fl
Na: 135mEq/L (136-148mEq/L) AST: 44 IU/L (5-40IU/L) L: 7%(20-45)% MCHC: 33.2 g/dl
M: 5% (0-10)% ESR:25(0-20mm/hr)
K: 3.6mEq/L (3.5-5.0mEq/L) ALT: 32 IU/L (5-40IU/L) E: 1%(0-5)% MCH: 29.5pg
FBS: ALP: 50 IU/L (40-140IU/L) B: Haematocrit:41.7%

PPBS: Platelets: 114×10ˆ3 (1-4lakhs)

URINE ANALYSIS OTHERS
pH: WBC: Creatinine phospho kinase(CPK): 79U/L
TSH: 0.819µIU/ml
Protein: RBC:
Peripheral smear reports: RBC-
Sugars: EP. Cells: Normocytic,normocytic, WBC normal in no.
QBC malaria- ring forms & schizonts of P. Vivax&
Blood: Casts:
few rings of P.falciparum seen
Ketones: Crystals:
FINAL DIAGNOSIS: P. vivax & falciparum malaria
DISCHARGE MEDICATIONS:
FOLLOW UP/REVIEW:
1) T. Malarid DS 1-0-1/2 × 14 days To review in med 7 OPD on Wednesday 26-12-12 with
2) T. Pantodac 40mg × 7 days CBC,MPQBC
3) T, Supradyn 0-1-0 × 14 days
4) T. Domstal 10mg 1-1-1 × 3 days