PROFORMA

ROLE OF IRON CHELATING IN CASE OF SICKLE CELL ANAEMIA AND THALASSEMIA

DEMOGRAPHIC DETAILS:
Name: Age: Sex: IP No:

Height: Weight: DOA: Dr:

Reason for admission:

H/O of present illness:

Past history:

Family history:

Systemic review:

CNS: GU:

CVS: MSK:

GIT: ENDOCRINE:

RS: OTHERS:

Vital signs:

Temperature: Bp: mmHg PR: b /min RR: /min

Drug history:

Birth history:

Immunization history:
Hematology:

Hb 12-18 g/dl Hematocrit(PCV) 36-46%

RBC 4.5-6 m/cm MCV 83-101 fl
T.WBC 4000-11000 MCH 27-32pg
cells/cumm
Neutrophils 45-75% MCHC 36-46 gms%
Lymphocytes 20-40% T.Iron binding cap.
Eosinopils 1-6% %transferrin saturatn
Monocytes 2-10% S.ferritin
Basophils 0-1% S.phosphorus
Platelet count 1.5-4.5 S.calcium
ESR
HPLC:

HbAO:

HbA2:

HbF:

DNA:

No.of transfusions:

Amount of blood transfused:

Hb% before transfusion:

Hb% after transfusion:

HbsAg:

HIC:

HCV:

Electrolytes:

Serum Sodium 135-145mmol/L

Serum Potassium 3.5-5.3mmol/L
Serum Chlorides 98-107mmol/L
Creatinine 0.6-1.3mg/dL
Blood Urea 10.0-40.0mg/dL
LFT:

Total serum proteins 6.0-8.0g/dL

Serum Albumin 3.5-5.0 gm/dL
Globulin 2.3-3.5gm/dL
A/G Ratio 1.2-2.2
Total Bilirubin 0.0-1.2mg/dL
Direct Bilirubin 0.0-0.3mg/dL
SGOT(AST) 0-40 U/L
SGPT(ALT) 0.0-40.0 U/L
ALP 42-142 U/L

TFT:

TSH:

T 3:

T 4:

Other investigations:

Treatment:

Brand Name Dose Frequency ROA Generic Name