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Justice K.S. Hegde Hospital, Deralakatte, Mangaluru: Patient Profile Form Department of Pharmacy Practice, Ngsmips

This document contains a patient profile form from the Department of Pharmacy Practice at Justice K.S. Hegde Hospital in Mangaluru, India. It provides details about a 62-year-old male patient admitted on April 11th, 2022 with complaints of tingling, numbness, vomiting, increased thirst and urination. His medical history includes type 2 diabetes mellitus. Routine tests showed uncontrolled diabetes. He was diagnosed with uncontrolled diabetes mellitus type 2 and discharged on April 15th with medications including Metformin, insulin, and supplements.

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Chaitrashree Gururaj
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285 views3 pages

Justice K.S. Hegde Hospital, Deralakatte, Mangaluru: Patient Profile Form Department of Pharmacy Practice, Ngsmips

This document contains a patient profile form from the Department of Pharmacy Practice at Justice K.S. Hegde Hospital in Mangaluru, India. It provides details about a 62-year-old male patient admitted on April 11th, 2022 with complaints of tingling, numbness, vomiting, increased thirst and urination. His medical history includes type 2 diabetes mellitus. Routine tests showed uncontrolled diabetes. He was diagnosed with uncontrolled diabetes mellitus type 2 and discharged on April 15th with medications including Metformin, insulin, and supplements.

Uploaded by

Chaitrashree Gururaj
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

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: [Link] 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:
[Link]: 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
[Link] 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) [Link] OD plus 500mcg 0-1-0 2 weeeks
3) [Link] 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

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