Navodaya Education Trust ®
N.E.T. Pharmacy College, NMCH & RC
Raichur
Department of Pharmacy Practice
Intercom: 322 Web: [Link]/pharmacy Email: pharmacypracticenet@[Link]
DATA ENTRY FORM
IP NO: 63139/24
Patient Name: Age: Gender: Weight & Height:_
[Link] 33years Female
Consultant: Dept/Ward: DOA:14/12/2024 DOD:17/12/2024
[Link] General medicine
Reason for admission: C/O _ cough since 15 days
_ weight loss since 15 days
_ chest pain since 3 days
_ breathlessness since 15 days
_ loss of appetite
Past medical history: N/H/O - T2 DM, HTN, PTB , Epilepsy,Asthma
Past medication history:
Nothing significant
SOCIAL HISTORY Marital status: Married
Smoker: Y/N N Alcoholic: Y/N : N Known allergies: Not know to
Tobacco in any other form: Y/N N Patient
VITAL SIGNS
Date 1
BP 110/80 mmHg
(mm/Hg)
Body Temp 97.6
(F)
Pulse Rate 86
(bpm)
Resp. Rate 18
(cpm)
PHYSICAL EXAMINATION:
Nill
LABORATORY INVESTIGATIONS: BLOOD / URINE / OTHER SAMPLE
TEST TEST VALUE NORMAL TEST TEST VALUE NORMAL
VALUE VALUE
Hb 8.2g/dL 11.5 - 14.5 WBC 13700 C/mm3 4000 - 11000
Rbc 3.6 milli/mm3 3.8 - 4.8 MCH 22.9 Pg 27- 32
Platelet 4.7 L/mm3 1.5 - 4.5 RDW-CV 16.8% 1.4 - 14 %
PCV 28% 36 - 46% MCHC 29.4 % 32-35
MCV 78fl 82 - 100
Glucose 115 mg/dL 80-140
OTHER INVESTIGATIONS:
Nill
DIAGNOSIS: Pneumonia
MEDICATION CHART
Sl. PRESCRIBED DRUGS DOSE, DATES OF TREATMENT
ROA,
N FREQUENCY
O [Link] [Link] 1 2 3 4 5
1 Inj .iv fluid Normal saline & @100ml/ hr, ✔ ✔ ✔
1pint DNS Dextrose Saline IV
2pint NS
2 Inj Amoxicillin 1.2g in ✔ ✔ ✔
Amoxicillin clavunate 100ml,iv ,bid
3 Tab Azithromycin 500 mg ,po ✔ ✔ ✔
Azithromycin OD
4 Tab Pan40 Pantoprazole 40 mg Po BD ✔ ✔ ✔
5 Tab Oseltamivir 75 mg bid PO ✔ ✔ ✔
oseltamivir
6 Tab Dolo Paracetamol 650mg po ✔ ✔ ✔
once daily
7 [Link] Terbutaline 15 ml po tid ✔ ✔ ✔
brametoxine hcl
8 Neb dualin Ipartropium bromide 1.25mg,TID ✔ ✔ ✔
lexosalbutamol
9
10
11
12
13
14
15
16
17
Sign & Name of the student Sign & Name of the Preceptor
