CASE PRESENTATION ON

Reg. No :
Year : 3th YEAR Pharm. D
 PATIENT’S PROFILE

IP No : Ward/ Unit :
DOA : DOD :
Gender : Marital Status :
Age : Education :
Weight (in kg) : Height (in cm) : Occupation : --
SOCIAL HISTORY
Tobacco chewing :
Tobacco smoking :
Alcoholic :
Any other relevant :
 REASON FOR ADMISSION
Present complaints :

Past medical history

Past medication history

Past surgical history

Allergic history to any drugs

Drug – drug interactions

Drug – food interactions

 PHYSICAL PARAMETERS
VITAL SIGNS
Physical Examination +/- GENERAL EXAMINATION

Pallor TEMPERATURE :
Icterus BLOOD PRESSURE :
Clubbing PULSE RATE :
Cyanosis RESPIRATORY RATE : SPO2:
Koilonychia SYSTEMIC EXAMINATION
Ly’edenopathy RS :
Edema CVS :
CNS :
ABD :
 PROVISIONAL DIAGNOSIS:

:
 LABORATORY INVESTIGATIONS
Lab test -CBC/HAEMATOLOGY TESTS Observed value Reference value

Hb

RBC

WBC

NEUTROPHILS

LYMPHOCYTES

EOSINOPHILS

MONOCYTES

BASOPHILS

PLATELETS

ESR
 LABORATORY INVESTIGATIONS
LAB TEST - BIOCHEMICAL INVESTIGATON Observed value Reference value

BUN (BLOOD UREA NITROGEN)

SERUM CREATININE

NA++

CA++

Cl-

K++

URINE ANALYSIS

COLOUR

ALBUMIN
 LABORATORY INVESTIGATIONS
Observed value Reference value

LAB TEST - DIABETES MARKERS

FBS 70 – 110 mg/dL

RBS 80 – 120 mg/dL

PPBS <140 mg/dL

HbA1C --- 4- 5.6%

 LABORATORY INVESTIGATIONS
LAB TEST - LIVER PROFILE Observed value Reference value

TOTAL BILLIRUBIN 0.3–1.3 mg/dL

DIRECT BILLIRUBIN 0.1–0.4 mg/dL

INDIRECT BILLIRUBIN 0.2–0.9 mg/dL

SGOT (AST) 12–38 units/L

SGPT (ALT) 7–41 units/L

TOTAL PROTEIN 6.2 – 8.1g/dl

ALKALINE PHOSPHATE (ALP) 33–96 units/L

LABORATORY INVESTIGATIONS :
 SOAP ANALYSIS
SUBJECTIVE EVIDENCE OBJECTIVE EVIDENCE
 FINAL DIAGNOSIS

 Based on subjective and objective evidences

the patient was diagnosed with
 TREATMENT CHART
Brand name/Generic name ROA DOSE FREQ D D D D D D D D D
1 2 3 4 5 6 7 8 9
 PHARMACEUTICAL CARE PLAN
GOALS OF THE TREATMENT

Short term goals Long term goals

* *
MONITORING PARAMETERS
Disease related Drug related
 Drug – Drug Interactions
s INTERACTIN SEVERITY OF THE EFFECT MANAGEMENT
n INTERACTION
G DRUGS
Majo Modera Mi
r te nor

4
.

5
.
 Drug – Food Interactions

SI. INTERACTING SEVERITY OF EFFECT MANAGEMENT

NO DRUG<>FOOD
INTERACTION
Major moderate mild
1.
 DRPS
1. Un treated indication :
2. Improper drug selection :
3. Sub therapeutic dose :
4. Over dosage :
5. Adverse drug reaction :
6. Drug interactions :
7. Failure to receive drug : Yes/No
8. Drug used without indication :
9. Others if any :
 GOALS ACHIEVED
*
 DISCHARGE MEDICATION
SL Prescribed drugs Dose Frequency No.
no. DAYS
Trade name Generic name
1

3
 PATIENT COUNSELLING
• Disease :
• Medication :
• Diet :
• Exercise :