PATIENT PROFILE FORM

PATIENT NAME: xyz HOSP. NO: DATE OF ADMISSION:

AGE: 65 yrs WEIGHT: 70 kg SEX: Male DATE OF DISCHARGE:

COMPLAINTS ON ADMISSION

Hypertension

MEDICAL HISTORY: hypertension from 7 years

MEDICATION HISTORY:
SOCIAL HISTORY
FAMILY HISTORY:
PREVIOUS ALLERGIES:

PHYSICAL EXAMINATION:
GENERAL
VITAL SIGNS - BP- 160/90 mmhg, PR- 90/min, RR- 22 /MIN
HEENT -
CVS -
RS -
GIT -
GU -
EXT -
CNS -
PROVISIONAL DIAGNOSIS: Hypertension

ROUTINE BIOCHEMICAL INVESTIGATIONS HAEMATOLOGY:

Urea: RBS: Alb: RBC : Retics:
S.Cr : Tch : Glob: WBC: Hb:
AST: N: PCV:
Na: TGs : L: MCV:
ALT: M: MCH:
K: T Bili:
ALP: E: MCHC:
FBS: D Bili:
B: ESR:
PPBS: T. Prot: Platelets:

URINE ANALYSIS OTHERS

pH: WBC: Uric Acid –
Protein: RBC: Cloride –
Sugars: EP. Phosphate –
Blood: Casts: TSH –
Crystals: T4 –
Stool – CXR –
XR –
FINAL DIAGNOSIS:- Hypertension
DRUG TREATMENT CHART: PROGRESS CHART:
DRUG WITH DOSE & ROUTE
DURATION OF THERAPY DAY INVESTIGATIONS
GENERIC NAME BRAND NAME

Furosemide Lasix 40mg D1-D12

Amlodipine Amlong 10mg D1-D12

Pantaprazole Pantodac 40mg D1-D12

Hydrochlorthlazide Moxovas 0.3 mg D1-D12

Prazosin Prazopress XL D1-D12

5mg

Febujet 40mg D8-D12

Sildefinil

Aerodil D11-D12
Promethazine+codiene

Levisiz 5mg D11-D12

Levocetrizine

DISCHARGE MEDICATIONS:

Not yet discharge

REVIEW: