PHARMACY PATIENT PROFILE FORM No - 2

I. ASSESSMENT
Treating Physician (Qualification):
Pharmacist: No
A. PATIENT’S DEMOGRAPHIC DETAILS
Name Kelifa shafi
Gender male
Age 27
Weight
Height
BMI
Card Number 0086468
Pregnancy and breast
feeding
Occupation police
Living condition poor
Address Adiss abeba
Room and bed 817/2
Religion Muslim
Date of admission 29/7/15
Patient stay 8
B. PATIENT’S CLINICAL INFORMATION
chiefe compliant
Physicians diagnosis Ankle joint dislocation
History of present Ankle joint dislocation
illness

Subjective findings Faling down accident of two weeks of durations

Objective P/E Ga stable
findings Cns conscious
ECG
Echo
PA
CXR
Date 02/06/23
PLT
WBC
Laboratory

RBC
MCV
MCH 31.9 H
MCHC
Hct
 Hgb
Lymphocytes
Neutrophils
SCr
ESR
SGOT
SGPT
U/A Protein
Glucose
Ketone
WBC
RBC
Epithelial cells
Glomerular casts
V/S BP 110/70
Temperature 36.9
RR
PR 88
Family history There is no any other disease in his family
Social history No smoking
C. Current Medication Record
Date 29/7/15 Ceftriaxone 1g iv bid
Heparin 7500 iv bid
Diclofenac 75mg I'm PRN

D. PATIENT’S MEDICATION EXPERIENCE

I) Patient’s No medication experiences
description
of medication
experiences
II) Patient’s Ceftriaxon
comprehensive Heparin
medication history Diclofenac injections
E. PATIENT’S DRUG RELATED NEEDS
IV) Assessment of the The medication is safe to treat medical conditions
patient’s drug related The medication is effective product is being used
needs The dose of the medication is achieving goals of therapy
The medication is safe,there are no adverbs drug reaction
The patient is compliant
F. DRUG THERAPY PROBLEMS
V) Identification of Indicated for Therapeutic goal
drug therapy Drug product,effective drug and no adveres drug reaction
problems Dosage regimen,effective dose
Compliance
 II. CARE PLAN AND FOLLOW UP EVALUATION
Medical condition I: Ankle joint dislocation
Symptoms:-Pain In The Joint Area
Sign÷ Dislocation of Ankle joint
Goal of Therapy÷ Reduce the pain and back the ankle to there area
Interventions:- give medications for treatment of pain and treat the joint
Counseling given: Treat based on directions of your doctors
Medical Current DTPs Therapeutic Therapeutic Rational Monitoring
Problem Drug Goals Recommendations
Regimen
Ankle ceftriaxon No DTP Back the Treat pain and back Back in to First treat
joint Heparin joint in to the joint in to your your area the pain and
dislocatio Diclofenac your area area because no then back
n injection walking so the joint in
the joint to there area
back in to and follow
there area up until
for walki g treated fully
and start
walking
FOLLOW-UP PARAMETERS

Clinical parameters for effectiveness evaluation: Improvement in pain but no the diseaee
Clinical parameters for safety evaluation:No undesirable effects of drug therapy
Laboratory parameters for effectiveness evaluation: there is no improvement in indicators of the
disease
Laboratory parameters for safety evaluation: No indicators of harmful effects of drug therapy
FOLLOW-UP RESULTS
Treat the pain but still Ankle joint dislocated so continious therapy needed
Medical condition II: Ankle joint dislocated
Symptoms:- Relive pain
Signs:- Ankle joint dislocated
Goal of therapy: relaif pain and back the joint in to there area
Interventions: Initiate drug therapy and treat the joint
Counseling given: stay and treatd as Directed by Physician Until treated from this
Medical Current DTPs Therapeutic Therapeutic Rational Monitoring
Problem Drug Goals Recommendations
Regimen
Ankle Ceftriaxon No Treat pain Back the joint in to If no treated
joint Heparin and back the there area the joint
dislocatio Diclofenac joint in to unable to
n injections your area walking so
treated the
joint
FOLLOW-UP PARAMETERS
Clinical parameters for effectiveness evaluation: improved pain
Clinical parameters for safety evaluation: There is no undesirable effect of drug therapy
Laboratory parameters for effectiveness evaluation: There is no improvement of in indicators of the
disease
Laboratory parameters for safety evaluation: There are no indicators of harmful effects of drug therao y

FOLLOW UP RESULTS

The stages of wound healing are a complex and fragile process. Failure to progress in the stages of wound
healing can lead to chronic wounds. Factors that lead up to chronic wounds are venous disease, infection,
diabetes and metabolic deficiencies of the elderly. Careful wound care can speed up the stages of wound
healing by keeping wounds moist, clean and protected from reinjury and infection. follow up results there
are non-dissolvable stitches or staples, health provider provider will remove them within 3 to 21 days also
a segmental fractures and it will treated by surgery resting and icing the affected area, followed by
controlled exercises that help restore range of motion, improve muscle strength and promote bone
healing.

Remodeling or also known as maturation phase is the last and final phase in wound healing and lasts
from 21 days up to 2 years. In this final and longest phase, collagen synthesis is ongoing in order to
strengthen the tissue. Remodeling occurs as wound continues to contract and fibers are being reorganized.
Recommendation

If You have symptoms of infection, such as:

*Increased pain, swelling, warmth, or redness.
*Red streaks leading from the area.
*Pus draining from the area.A fever.

If You got trouble breathing.

*Watch closely for changes in your health, and be sure to contact your doctor or nurse advice if:
You do not get better as expected.
Lastly the doctor prescribed antibiotics or othe medications take the medicines as directed. Do not stop
taking them just because you feel better. You need to take the full course of medicine.

Treat the pateint fully from that pain and until he start walking