SRI VENKATESWARA COLLEGE OF PHARMACY

RVS NAGAR, TIRUPATHI ROAD, CHITTOOR – 517127 (AP) INDIADEPARTMENT OF PHARMACY PRACTICE

Case Record

Student Name: Year & Course:Case Record No.: Recorded Date:

PATIENT PROFILEName Sex: Age:

Date of Admission Ward IP No.

Reason for Admission

On Examination

Provisional Diagnosis

Medical History

Medication History

Social History Family History

Allergy (food / drug) if any:

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Clinical Hematology Normal reference range (units)

Patient Value Conventional SIHemoglobin (Hb) Male

Female

Total Count

Differential Count Polymorphs

Lymphocytes

Eosinophils

Erythrocyte

Sedimentation Rate (ESR)

Male

Female

Platelet Count

Complete Blood CountRed Blood Cells (RBC) Male

FemaleHematocrit (Hct) / Packed Cell Volume (PCV)

MaleFemale

Mean Cell Volume (MCV)

Mean Cell Hemoglobin (MCH)

Mean Cell Hemoglobin Concentration (MCHC)

Bio-ChemistryBlood Sugar Fasting (F)

Post Prandial (PP)Random (R)

ElectrolytesSodiumPotassiumCalcium

Lipid ProfileCholesterolTriglycerides

Low density lipoprotein (LDL)

Renal Function Test

Serum creatinine (Sr.Cr)

Blood Urea Nitrogen (BUN)

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Liver Function Test

Aspartate Amino transferase (AST / SGOT)

Alanine amino transferace (ALT / SGPT)

Alkaline Phosphates (ALP)

Bilirubin Total

Direct

Indirect

Bleeding Time

Clotting Time

Prothrombin Time

Activated Partial Thromboplastin

Urine Analysis

Urine Sugar

Urine albumin

Ketone Bodies

Deposits Pus cells

Epithelial pus cells

RBC / Granular Cyst

Bile Salts

Bile Pigments

Direct bilirubin

Drug(s) prescribed on admission

S.No Drug(s) Name Dose Frequency Drug Indication

Brand Name Generic Name

Drug(s) Prescribed

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Date

O/E Patient Complaints

Drug Prescribed Dose Frequency IndicationBrand Name

Generic Name

Drug Interaction: Yes/No(If Yes details)

Drugs on Discharge

Remarks:

Student’s signature: Staff In-charge

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