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    Patient Profile Form Department of Pharmacy Practice, Mcops, Manipal

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    varish
    This patient profile summarizes the medical history, hospital course, and discharge plan for a 65-year-old male admitted with recurrent UTI, urosepsis, and CKD. Key details include a history of diabetes, hypertension, BPH, and NHL. During his hospital stay he was treated with antibiotics, insulin, and other medications. His condition improved and he was discharged with medications including insulin, pantoprazole, and statins, and instructed to follow up in the medicine clinic in one month.

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    Patient Profile Form Department of Pharmacy Practice, Mcops, Manipal

    Uploaded by

    varish
    62 views4 pages
    This patient profile summarizes the medical history, hospital course, and discharge plan for a 65-year-old male admitted with recurrent UTI, urosepsis, and CKD. Key details include a history of diabetes, hypertension, BPH, and NHL. During his hospital stay he was treated with antibiotics, insulin, and other medications. His condition improved and he was discharged with medications including insulin, pantoprazole, and statins, and instructed to follow up in the medicine clinic in one month.

    Original Title

    UTI PPF Group 5-Converted

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    This patient profile summarizes the medical history, hospital course, and discharge plan for a 65-year-old male admitted with recurrent UTI, urosepsis, and CKD. Key details include a history of diabetes, hypertension, BPH, and NHL. During his hospital stay he was treated with antibiotics, insulin, and other medications. His condition improved and he was discharged with medications including insulin, pantoprazole, and statins, and instructed to follow up in the medicine clinic in one month.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    62 views4 pages

    Patient Profile Form Department of Pharmacy Practice, Mcops, Manipal

    Uploaded by

    varish
    This patient profile summarizes the medical history, hospital course, and discharge plan for a 65-year-old male admitted with recurrent UTI, urosepsis, and CKD. Key details include a history of diabetes, hypertension, BPH, and NHL. During his hospital stay he was treated with antibiotics, insulin, and other medications. His condition improved and he was discharged with medications including insulin, pantoprazole, and statins, and instructed to follow up in the medicine clinic in one month.

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    © All Rights Reserved
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    of 4

    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.

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