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Patient Profile Form: of Pharmacy Practice, ISF College of Pharmacy, Moga-142 00
Patient Profile Form: of Pharmacy Practice, ISF College of Pharmacy, Moga-142 00
Complaints on Admission:
Physical Examination:
General :
Central Nervous System (Orientation/Head/Consciousness/Calm/Aggressive/Depression):
Cardiovascular (Edema/ Pallor /Koilonychia /Cyanosis /Clubbing / Icterus / Lymphatic Node enlargement):
BP: PR: Heart:
Body Temperature:
Respiratory (Nose/Thorax/Respiratory Rate):
Gastrointestinal (Abdominal/diarrhea/constipation/Pain):
Senses (Eyes/Smell/Hearing/Pain/Taste):
Genito-urinary system (Urination/Uterus/Testis):
Others:
Provisional Diagnosis:
Parameters Observed value Normal Range Parameter Observed Value Normal Range
HEMATOLOGY: LIPID:
M 14-18g/dL Total cholesterol <5.2mmol/L
Hemoglobin
F 12-16g/dL LDL <4.13mmol/L
Hemoglobin -
HDL 1.03mmol/L
A1c
RBC M 4.3-5.9x10 /L
12
Triglycerides <1.70mmol/L
M 0.39-0.49 DIABETOLOGY:
Hematocrit
F 0.33-0.43 Fasting Glucose 70-99 mg/dL
M 0-15 mm/h Pre-Prandial Glucose 70-130 mg/dL
ESR
F 0-20 mm/h Post-Prandial Glucose >140 mg/dL
M 35-155ug/dL Random Glucose 80-120mg/dL
Iron
F 50-170ug/dL RENAL:
MCV 76-96fLa Blood Urea 15-45 mg/dL
MCH 27-32pg BUN 5-17 mg/dL
MCHC 31-35% Sr. Creatinine 0.8-1.3 mg/dL
TLC 4000-10000cumm Sr. Uric acid 2.4-7.0 mg/dL
Neutrophils 40-70% Sodium 135-155 mEq/L
Eosinophils 1-4% Potassium 3.5-5.5 mEq/L
Basophils 0-0.5% Chloride 98-107 mEq/L
Monocytes 2-8% Calcium 9.2-11.0 mg/dL
Lymphocyte 20-45% Bicarbonate 23-28 mEq/L
Platelets 1.5-4.0 Lakh/cumm UROLOGY:
PTI 90-100% pH 5.0-9.0
BT 1-4 min Sugar 100-260 mmol/d
CT 3-10 min Protein 150 mg/d
PT 9-12 sec Albumin
TYPHI(widal card) +/- RBC 0-3 cells
LIVER: WBC 0-1 cells
Bilirubin-Total 0.3-1.1mg/dL EP Cell Nil
Direct 0.1-0.5mg/dL Puss cell Nil
ALT 5-40 IU/L Crystals 0-4
ALP 60-150 IU/L Casts
Unconjugated 0.2-0.7 mg/dL OTHER INVESTIGATIONS:
THYROID:
T3 1.2-2.1nmol/L
T4 70-151 nmol/L
TSH 0.4-5 munits/L
Free T3 3.7-6.5pmol/L
Free T4 10.3-21.9pmol/L
Interpretation in consultation with physician:
Pharmacist Interventions:
Department of Pharmacy Practice
ISF College of Pharmacy, Moga-142 001
Case Evaluation Form
Student Name:
Class:
Case No:
Data Collection Date:
Presentation Date:
Parameters Marks
Data Collection
Interaction Ability
Case Understanding
Presentation of case
Discussion of case
Drug Therapy changes
Patient counseling
Communication
Review Writing Skill
Overall Assessment
Max Marks 10
…………………………………………………………………………………………………………….
Student Signature:
Preceptor
(Name, Signature, Date)