Patient profile (Taking & Components)

Patient Profile for students of MBBS, PHARM.D, BDS, DPT

1. PATIENT PROFILE Produced by: Dr.Sana J aved Pharm.D,(M.Phil . Pharmaceutics ), Ph.D. scholar Assistant professor Lahore Pharmacy College Of Lahore Medical & Dental College Pakistan.

2. Patient profile It is a report of patient’s disease progress including the information and reasoning behind the diagnosis and the management decision. Patient profile

3. Significance The purpose of patient profile is to provide a history of patient’s previous medication including a note of idiosyncrasy, adverse drug reaction, allergies together with a record of his current medication, its enables the practitioners, and pharmacist to monitor patient’s medication Patient profile

4. Patient details A patient profile is conventionally prefaced by a brief description of the patient. The patient detail contain following information. Name age Sex race Occupation address Weight medical record number Ward D.O.A (date of admission) Parts of patient profile

5. 2. Presenting complaints Theses are the complaints that have brought the patient to clinic. These should be listed and should be written in chronological order Parts of patient profile

6. 3. History of present illness Should be written in patient’s own language Write in paragraph form Never ask leading questions Keep quiet and let the patient to speak Parts of patient profile

7. 4. Past medical history a. Childhood history Birth history i.e., normal, premature, past mature, disease of childhood b. Immunization history Complete or incomplete c. Adolescence history Any medical problem from childhood to adult Parts of patient profile

8. d. Adult hood history Accidents, trauma, disease e. non-prescription medication use To prevent drug-drug interaction 5. Past surgical history Any surgical procedure done in the past e.g., appendectomy Parts of patient profile

9. 6. Medication history Current medication self medication oral contraceptives Adverse effects 7. Allergies Any kind of drug or food allergies Parts of patient profile

10. 8. Family history Because many diseases have a significant genetic basis. It may include epilepsy, cv diseases, hypertension, diabetes. 9. Personal history Habits, addiction, smoking, sleep habits, sexual habit, food etc Parts of patient profile

11. 10. Socio-economic history It is asked for selection of brands. It includes Financial state, domestic situation, mobility, surroundings 11. Examination O/E It may be general or systemic General examination e.g., temperature, pulse rate, B.P, respiration rate Parts of patient profile

12. Systemic examination Exam of each system e.g., Cardio vascular system-heart sounds Respiratory system-chest exam GIT- Abdomin exam Skin-allergy, paler Eye- pupil exam, light reflex Parts of patient profile

13. 12. Investigations x-ray, CT-scan, MRI Blood profile : WBC, RBC, Hb, DLC, platelet count Electrolyte : sodium, potassium, chloride Renal profile : urea, creatinine level, pus contents Hepatic : ALT, AST billiribin Parts of patient profile

14. 13. Diagnosis A brief diagnosis is usually clear by this stage. Alternatively it will be provisionally awaiting for confirmation from investigation 14. Management Each profile should conclude with management plan. Management should be according to diagnosis, physician, nurses and pharmacist Parts of patient profile

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