PATIENT CLINICAL PROFILE
Personal Information
Demographics
Patient initials: R.S Age: 78 years Gender: Male Ethnic origin: Pathan (Darband)
Weight: 92 kg Height: N/A BMI: N/A
Occupation: N/A
Important Notes/ comments: N/A
Presenting Chief Complaints
The chief complaints presented by the patient are:
SOB-Shortness Of Breath
General Weakness (From Last Night)
Confusion
Loss Of Appetite
Past Medical History
The patient suffered from the following illness in the past:
CKD-(Chronic Kidney Disease)
DM-(Diabetes Mellitus) For The Past 23 Years
HTN-(Hypertension)
History of Allergies: Medication Allergies (reaction---rash, shock, asthma, nausea, anemia)
Please specify what patient is allergic to and the nature of reaction to the allergen.
No history of allergies.
Social History (Soc. Hx): please ask questions which are relevant and appropriate to the
patient (e.g. exercise, use of: tobacco, alcohol, recreational drugs, Sheesha, Naswar, others).
Quantify information where possible (e.g. units of alcohol, frequency of exercise).
The patient, due to old age, was unable to exercise and was recommended cholesterol
lowering drugs rather than exercise.
Smoking pack years:
The patient smokes 3 cigarettes per day on average. He smokes an average of 1095 cigarettes
in one year that makes 54.75 packs in one year.
What does patient monitor at home/ need to monitor at home?
Patient, diabetic and hypertensive, needs to monitor blood pressure and blood sugar level
regularly at home.
Diagnosis/Assessment:
General Examination:
The general assesment includes:
a. General Physical Examination:
It includes:
i. Anaemia
Positive
ii. Edema:
Positive
b. Systemic Examination:
It includes:
i. R.S
Crepts present
ii. C.V.S
S1 and S2
iii. C.N.S
Oriented power 4/5
c. Local Examination:
Left foot ulcer present
Edema present
Diagnosis:
The patient has Diabetic Complications.
Lab Investigations
Vital signs:
BP = 140/80 mmHg
RR = 32 breaths/min
PR = 96 b/min
Temperature = 98 F
ELECTROLYTES
Normal Observed Comment on significance of
Test Dates/s
values values result
17/11/1
Na 135-145 mEq 97 mEq Due to past CKD.
8
Cl N/A N/A N/A N/A
3.6-5.2 17/11/1
K 6.1 mmol/L Past CKD.
mmol/L 8
HEMATOLOGICAL TESTS
Normal Observed
Test Dates/s Comment on significance of result
values values
13.5-17.5
Hgb test 17/11/18 9.8 g/dL Anaemia
g/dL
LIPID PROFILE (FASTING)
Normal Observed Comment on significance of
Test Dates/s
values values result
100-129 17/11/1 Patient has high cholesterol level
LDL 189 mg/dL
mg/dL 8 and HTN.
40-59 17/11/1
HDL 91mg/dL Due to high cholesterol.
mg/dL 8
BS & HbA1c
Normal Observed Comment on significance of
Test Dates/s
values values result
79-160 17/11/1
RBS 172 mg/dL Diabetic
mg/dL 8
70-110 17/11/1
FBS 118 mg/dL Diabetic
mg/dL 8
Medication History (prescription and non-prescription medicines/ home remedies/
herbal/ homeopathic, pre-admission)
Medication name How used
Start
(brand & generic) Route (dose, Comment, reason for use
Date
and strength frequency)
Inj. INSULIN-R Inj. For 0.4 For diabetes mellitus
(Insulin) 10mL vial last units/kg/day
23 O.D
yrs
TREATMENT REGIMEN
PRESCRIBED REGIMEN:
Medication name How used
Start
(brand & generic) Route (dose, Comment, reason for use
Date
and strength frequency)
Insulin Inj. Actrapid I/V 17/11/18 30.7 BD To be continued for maintanence
30.7 OU of DM.
Amlodipine 5mg For maintenance of HTN.
I/V 17/11/18 5 mg BD
CASE ANALYSIS & DISCUSSION
SIGNIFICANT FINDINGS OF MEDICATION HISTORY:
Number of Drugs: 2
Name of Drugs
• Amlodipine
• Insulin
Allergy: No known allergy
ADR’s: No ADR’s were observed
Clinical Importance
Patients was taking insulin 25 units BD.
MEDICATIONS USED IN HOSPITAL:
Number of Drugs: 2
DRUG No.1:
Actrapit (Insulin regular human)
Therapeutic class
Anti-diabetic
Available forms/strength
100 units/ml (3ml vial)
100 units/ml(10ml vial)
DRUG No.2:
Amlodipine (NORVASC)
Therapeutic class :
Antihypertensive, Calcium channel blockers
Available forms/strength
• 2.5mg
• 5mg
• 10mg
Indications
Skin & soft tissue infection
Dosage
Adult: 375mg thrice daily or 625mg twice daily or 1.2gm I/V for 2 weeks
DRUG No.3 :
Metformin
Therapeutic class
Biguanide
Available forms/strength
• Tablet: 250mg, 500mg, 750mg, 850mg, 1gm
Indications
Type 2 diabetes mellitus
Dosage
Adult: initially 500mg twice daily or 850mg daily with meals, increase by 500mg every week
or 850mg every 2 weeks (Max 2550mg)
ADR’s MONITORING: No ADR’s were observed
COMPLIANCE: Patient’s compliance was satisfactory
PATIENT EDUCATION & COUNSELING
Patient’s attendant was educated about diabetes. He was educated about diabetes control and
relevant monitory test and medications including proper usage of insulin.
OUTCOME OF MEDICATION THERAPY
Patient’s glucose level was controlled and patient recovered.
ANALYSIS REPORT (SOAP)
Subjective Data:
A 78 years old man complains of Shortness of breath, general weakness from last
night, confusion and loss of appetite.
The patient attendant described the complaints appeared from last night.
The attendant also described that the patient has Diabetic complications.
Objective Data:
BP = 140/80 mmHg
RR = 32 breaths/min
PR = 96 b/min
Temperature = 98 F
Assessment:
Diabetic Complications:
SOB-Shortness Of Breath
General Weakness (From Last Night)
Confusion
Loss Of Appetite
Diabetes mellitus (DM), commonly known as diabetes, is a group of metabolic
disorders characterized by high blood sugar levels over a prolonged period.
Symptoms of high blood sugar include frequent urination, increased thirst, and
increased hunger.
If left untreated, diabetes can cause many complications.
Hospital treatment was in accordance with standard treatment and follow the standard
protocol of treatment and chief complaints revealed.
Standard treatment for DM is:
Insulin (Regular and Lispro)
Neutral Protamine Hagedorn
Glargine and Detemir
Sulfonylureas
Meglitinides
Diagnostic Tests:
Consider FBG for diagnosis of DM.
Consider Oral glucose tolerance test for DM.
Plan (include role of the pharmacist):
A follow up appointment should be made after 1-2 weeks.
Avoid Thiozolidinediones during DM.
Avoid dairy products, caffeine and sugar.
Include high-fiber foods, green leaves and low fatty products.
Exercise regulary to reduce LDL level.
Call for worsening symptoms
