PATIENT PROFILE FORM

DEPARTMENT OF PHARMACY PRACTICE, MCOPS, MANIPAL

PATIENT NAME: ABC HOSP. NO: 661 DATE OF ADMISSION: 30/08/2021

AGE: 65Y WEIGHT: - BMI: - SEX: M DATE OF DISCHARGE: 06/09/2021
COMPLAINTS ON ADMISSION: -Pedal Edema x 1 month
-Abdominal Distension x 2 weeks
-Cough with Dyspnea x 2-3 days
-Loose Stool 2 episodes 1 day back.
MEDICAL HISTORY: T2DM, HTN, BPH, NHL (4-5 years back)
MEDICATION HISTORY: Tab. Clinidip 10mg (1-0-0) Tab. Ecosprin AV 75/10 µgm (0-0-1)
SOCIAL HISTORY: Smoking (abstained x 6years)
FAMILY HISTORY: Nil
PREVIOUS ALLERGIES: NAD
PHYSICAL EXAMINATION: Conscious, oriented to time, place and person, unable to stand
GENERAL : P-I-C-C-L-E+ (pitting edema)
VITAL SIGNS – PR: 80bpm, BP: 120/80 mmHg, RR: 24/min, Temp: 98.8 F
HEENT - NAD
CVS - S1 S2 + , no murmurs
RS - B/L NVBS +
GIT - soft, distended, non-tender, BS+
GU - NAD
EXT - NAD
PROVISIONAL DIAGNOSIS:
UTI, Pre-Renal AKI?
ROUTINE BIOCHEMICAL INVESTIGATIONS(30/08/21) HAEMATOLOGY:
RBC: 4.19×106/µL Retics:
Urea: 68 mg/dL T Bili: 0.29 mg/dL Alb: 3.7 g/dL WBC: 8.9 x 10³/µL Hb: 9 g/dL
S.Cr: 2.05 mg/dL D Bili: 0.13 mg/dL Glob: 2.9 g/dL N: 77% PCV:
Na: 136.0 mmol/L T Prot: 6.6 g/dL AST: 43 IU/L L: 10.1% MCV: 68.2 fl
K: 4.4 mmol/L ALT: 38.0 IU/L M: 9.4% MCH: 21.5pg
RBS: ALP: 106 IU/L E: 2.5% ESR: 94
B: 0.3%
Platelets: 209×103/µL (giant)
URINE ANALYSIS OTHERS
pH: 5.5 WBC: 15.9 /hpf TSH: 0.560 µIU/mL
C-REACTIVE PROTEIN (CRP) (Serum):118.69 mg/L
Protein: - 1+ (30 mg/dl) RBC: - 5.60 /hpf TROPONIN T hs STAT (Serum):0.030 ng/ml
Sugars: - negative EP. Cells: - 1.70 /hpf HbA1C (Whole Blood):7.6 %
Blood: - 3+ (0.75) Casts: - 0.36 /hpf N-TERMINAL PRO B-TYPE NATRIURETIC PEPTIDE
(Serum):1919 pg/ml
Crystals: - 0 PTH (Plasma):91.8 pg/Ml
Urine culture: Isolated organism E.coli
FINAL DIAGNOSIS: Recurrent UTI, Urosepsis, CKD
 DRUG WITH DOSE & ROUTE 30/8 31/8 01/9 02/9 03/9 04/9 05/9

1 2 3 4 5 6 7
GENERIC NAME BRAND NAME
Ceftriaxone Inj. Ceftriaxone 2gm IV √ √
OD ATD

Human Insulin Inj. H. ACTRAPID s/c √ √ √ √ √ √ √

(0-6-6) (16-12- (14-0- (14-0- (0-10- (0-10- (0-10-
12) 0) 0) 0) 0) 0)

Pantoprazole Inj. PAN 40mg IV Q24H √ √

Ondansetron Inj. Emeset 4mg Q8H √ SOS SOS

Paracetamol Inj. Finamac 1gm IV √

SOS

Vitamin Supplement Inj. NS with lamp √

optineuron @50ml/hr

Vitamin C T.Limcee 500mg 1-0-1 √(1-1-1) √ √ √

Atorvastatin 10mg + T.Ecosprin AV 75/10 √

Aspirin 75mg 0-0-1

Atorvastatin 20mg + T.Ecosprin AV 75/20 √ √ √ √ √ √

Aspirin 75mg 0-0-1

Clinidipine T.Clinidip 10mg 1-0-0 √ √ √ √ √ √ √

Cefoperazone 1g + Inj. Viatran 3gm IV √ √ √ √ √ √ √

Sulbactam 0.5g Q12H

Normal Saline/ IVF NS/RL @75ml/hr √

Ringer’s Lactate

Multivitamin T.Cobadex czs 0-1-0 √ √ √ √ √ √

Insulin Aspart (30%) Inj. Novomix √ √ √ √ √

+ Insulin Aspart (28-0-
32)
(28-0-
32)
(42-0-
34)
(28-0-
32)
(28-0-
32)
Protamine (70%)

Pantoprazole T.Pan 40mg 1-0-0 √ √ √ √ √

Olesoft Lotion √ √ √ √
Furosemide Inj. Lasix 40mg IV √ √ √
STAT
DISCHARGE MEDICATION:
PROGRESS CHART:
DRUGS STRENGTH FREQUENCY NO. OF DAYS
T ECOSPRIN AV 75/20 0-0-1 CONTINUE DAY INVESTIGATIONS
T COBADEX CZS 0-1-0 CONTINUE
T PAN 40 mg 1-0-0 CONTINUE 30/08 Conscious, oriented. Adv. ECHO
PR-78bpm, BP- 140/80mmHg,
T BENIDIPINE 8 mg 1-0-0 CONTINUE
C PREGABALIN 75 mg HS CONTINUE 31/08 Conscious, oriented, fatigue, fungal infection
on both foot, dry skin on both upper and
OLEFORT LOTION CONTINUE lower limbs (ref. to dermatology)
INJ NOVOMIX 44-0-36 CONTINUE PR-80 bpm BP- 132/80 mmHg

01/09 Conscious, oriented, weakness present

PR – 82bpm, BP- 122/80mmHg
S.Cortisol:10.290 µg/dL , PSA (Serum): 5.11
ng/mL

02/09 Conscious, oriented, weakness present

Adv. Uroflometry
PR – 84bpm, BP – 130/80mmHg
S.Creatinine:1.42 mg/dL; S.Potassium:4.8
mmol/L; S.Sodium:138.0 mmol/L; Urea
(Serum):26 mg/dL; PPBS:334 mg/dL

03/09 Conscious, oriented, Itching in both legs,

Pyelonephritis
PR – 90bpm, BP – 130/80mmHg
S.Creatinine:1.41 mg/dL; S.Potassium: 5
mmol/L; S.Sodium:138.0 mmol/L; Urea
(Serum):25 mg/dL; FBS:264 mg/dL

04/09 Conscious, oriented and stable

Urine routine came normal.

05/09 Conscious, oriented and stable

FOLLOW UP/REVIEW:

To review with CBC and RFT after one

month in medicine 2 OPD on Wednesday.