PATIENT PROFILE FORM

DEPARTMENT OF PHARMACY PRACTICE, NGSMIPS

JUSTICE K.S. HEGDE HOSPITAL, DERALAKATTE, MANGALURU

Patient Initials: MD Hosp. No: 17104769 Age: 62 yrs Date of Admission: 11-04-2022

Gender: M/F: M Height: Weight: Date of Discharge: 15-04-2022

COMPLAINTS ON ADMISSION: tingling and numbness in UL and LL since 1 month, vomiting since two days, increased thirst
and urination.

MEDICAL HISTORY: K/C/O DM type II

MEDICATION HISTORY: T.Metformin 500mg 1-0-1

PERSONAL HISTORY: Diet mixed, sleep normal, appetite normal, bowel and bladder normal
FAMILY HISTORY:. Nothing significant
PREVIOUS ALLERGIES: NAD

PHYSICAL EXAMINATION:
GENERAL - Pt. was conscious, co-operative and oriented. Moderately built and nourished.
VITAL SIGNS - BP- 140/90 mmHg PR- 126 bpm,
HEENT -
CVS - S1 S2 (+), No murmur
RS - NVBS +, no added sound
GIT - soft, non tender

GU -

EXT -
CNS - no focal neurological deficit

PROVISIONAL DIAGNOSIS:

ROUTINE BIOCHEMICAL INVESTIGATIONS HAEMATOLOGY

Urea: 33mg/dL RBS: 336mg/dl Alb: 4.1 g/dL RBC : Reticulocytes:
S.Cr: 1.31mg/dL HDL: Glob: 2.80g/dL WBC: 17400 cells/mm3 Hb: 16.6g/dL
LDL: N:92 PCV:
Na: 141mmol/L AST: 12U/L L:10 MCV:
D Bili:0.19mg/dL
K: 3.88mmol/L ALT: 23 U/L M: MCH:
I Bili :1.06mg/L ALP:99 u/l E: 09 MCHC:
Cl :
Uric Acid: T Bili: 0.47mg/dL A/G Ratio – B: ESR: 52 mm/hr
FBS: 230mg/dl Iron: TIBC:
T. Prot:
Ferritin: Folate:
PPBS: Vit.B12: Platelet: 275000
URINE ANALYSIS OTHERS
pH: WBC:
Protein: RBC:
Sugars: EP. Cells:
Blood: Casts:
Crystals:
FINAL DIAGNOSIS: Uncontrolled diabetes mellitus type II
 DRUG TREATMENT CHART:
PROGRESS CHART:
DRUG WITH DOSE & FREQUENCY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
DAY INVESTIGATIONS
Brand Name Generic Name
C. Meganeuron OD Methylcobalamin vit B6 * * * * *
plus Folic acid benfotiamine Day 1 c/o vomiting. Tingling and numbness in UL and LL
0-1-0
Day 2 No fresh complaints
Inj H Actrapid Insulin
40-40-40 units SC acc to GRBS
* * * * *
Day 3 Patient symptomatically better
T.Emeset Ondansetron * * * * *
Day 4 Patient vomiting condition recovered
SOS 4 mg

T. Metformin Metformin 500mg * * * * * Day 5 Patient Discharged

1-0-1

DISCHARGE MEDICATIONS: 1) Metformin 500mg 1-0-1

2) T.meganeuron OD plus 500mcg 0-1-0 2 weeeks
3) T.Ondansetron 4mg sos
4) Inj H Actrapid 20-20-20 units acc to GRBS
FOLLOW-UP/REVIEW – Review in gen med I OPD after 2
weeks