A CROSS-SECTIONAL EVALUATION STUDY AND DRUG UTILISATION PATTERNS OF ORAL-

HYPOGLYCAEMIC AGENTS IN PATIENTS WITH TYPE II DIABETES MELLITUS IN A

TERTIARY CARE HOSPITAL

Sarada Vilas College of Pharmacy

Department of pharmacy practice
&
Apollo BGS Hospital, Mysuru.
Date:
Case No.
PATIENT CLINICAL PROFORMA
Patient Demographics:
Name Age Sex Weight Height BMI IP. No Department DOA DOD

Patient Medical History:

Reasons for Admission:

Past medical history:

• History of HTN: Yes No

• Co-morbidities: Yes No
• If yes, specify

Past medication history:

Social history: Smoker: Y / N Alcoholic: Y / N Marital status:

Tobacco use in any form: Y / N

Known Allergies:

Vitals:
Days 1 2 3 4 5 6 7 8 Indications
BP (120/80 mmHg)
Pulse (60-100bpm)
Body Temp (97-101℉)
RR (12-20 breath/min)
SPO2 (96-99%)
PATIENT DATA - QUERY REPORT
Laboratory Data:
Hematology:
Days 1 2 3 4 5 6 7 8 Indications
Hb:(g/dl) M: 12-16 F:11-14
WBC: 4,500-11,000mcL
RBC:M:4.7-6.1
F:4.2-5.7million cells/mcL
Platelets:150-400 x 10⁹/L
DLC Neutrophil (48-77) %
PLT Eosinophil (1-4) %
Basophil (0.5-1) %
Lymphocyte (10-40) %
Monocytes (2-8) %
PCV: (M:0.46 F:0.42) %
ESR: (M:1-13 F:1-20) mm/hr

Biochemistry:
Days 1 2 3 4 5 6 7 8 Indications
FBS (60-90 mg/dl)
RBS (90-110 mg/dl)
PPBS (80-150 mg/dl)
HbA1c (4-5.6%)
Urea (7-20 mg/dl)
Sr. Creatinine (0.84-1.21 mg/dl)
CKMB (3-5%)

Liver function tests:

Days 1 2 3 4 5 6 7 8 Indications
Total bilirubin (<1mg %)
P.T. Time (14 sec)
Alka. Phosphatase (84-306 U/L)
SGPT/ALT (7-56 U/L)
SGOT/AST (5-40 U/L)
LDH (140-280 U/L)
Bilirubin: Total: (0.1-1.2mg/dl)
Direct: (<.3mg/dl)

Renal function tests:

Days 1 2 3 4 5 6 7 8 Indications
eGFR (90ml /min/1.73m²)
Urea (mg %) (15-45)
Uric acid (mg %) F-2-5, M-2-7
Sr Creatinine (mg %) (0.6-1.4)

Electrolyte (mEq/L):
Days 1 2 3 4 5 6 7 8 Indications
Sodium (130-150)
Potassium (3.5 – 5.8)
Chloride (98-100)
Bicarbonate (22-36)
PATIENT DATA - QUERY REPORT
Fluid Intake & Output chart:
Days 1 2 3 4 5 6 7 8 Indications
Intake (ml)
Output(ml)

Urine examination:
Days 1 2 3 4 Days 1 2 3 4
Color Sugar
Bile salts WBC
Bile pigment RBC
Albumin Casts
Pus cells Epithelial cells

Lipid Profile:
Days 1 2 3 4 5 6 7 8 Indications
HDL (35-60mg/dl)
LDL (130-160mg/dl)
VLDL (2-30mg/dl)
Triglycerides (160-200mg/dl)
Total cholesterol (200-240mg/dl)

Microbiology:

Other investigation:

Diagnosis:

Current medication:
Sl. Name of medication DOSE ROA FREQUENCY Days of Treatment
No
Brand Generic D.1 D.2 D.3 D.4 D.5 D.6 D.7 D.8

1.

2.

3.

4.

5.

6.

7.

8.
PATIENT DATA – CLINICAL NOTES
Clinical Notes:
D.1 D.2

D.3 D.4

D.5 D.6

D.7 D.8

D.9 D.10

Clinical pharmacy services provided:

Activity Number Code Activity Number Code
1. 3.

2. 4.

Discussions / Interventions made

Student Name: Preceptor Name:

Signature: Signature:
PATIENT DATA – CLINICAL NOTES