PATIENT PROFILE

&
PATIENT COUNSELING

Chapter 3
Abdul Mateen
 3. PATIENT PROFILE & PATIENT
COUNSELING:
a) Patient disease profile
b) Taking case history
c) Drug profile of at least 25 Important Medications e.g.
Adrenaline, Aminoglycosides, Anti-TB Drugs,
Antiepileptics, Atropine, Benzodiazepines,
Cepahlosporins, Chlorpheniramine, Cimetidine,
Digoxin, Dobutamine, Dopamine, Fluroquinolone,
Furosemide, Lactulose, Macrolides, Metoclopramide,
Morphine/Pethedine, Nifedipine, NSAIDS, ORS,
Penicillins, Prednisolone, Salbutamol, Vancomycin.
d) Patient Counseling
 Case History
Ref: pharmacotherapy hand book “a case study”
Synonyms

Definition;
Comprehensive description of patient clinical conditions,
history along with the drug therapy.
OR
The data concerning an individual ,their family,
environment, including medical history that may be useful
in analyzing and diagnosing their case OR for instructional
purpose . OR
 Case History
A detailed account of a patients past and present state of
health obtained from the patient OR relatives.
OR
Information gained by a health care professional by
asking specific question either from the patient Or
relatives with the aim to formulate a patient drug related
needs and provide pharmaceutical care to the patient.
 Case History
Components:
1. Identification and Demographics;
Also called the patient personal information
• Patient name
Demographics
• Gender, marital status, child (how many), occupation…etc
• patient’s age, height, weight, race or ethnic origin, education,
occupation, and lifestyle.
• Lifestyle information includes the patient’s housing situation
(e.g., boarding house, private home, apartment, shelter, living
on the street), the people living with the patient (e.g., spouse,
young children, elderly relatives, extended family), and the
patient’s type of work and work schedule, if applicable (i.e.,
day shift, night shift, rotating shift schedule, part time, full
time)
 Case History
Physical examination (PE)
• The exact procedure performed during the physical
examination vary depending up on the chief complaints
and patient’s medical Hx.
• In some practice setting only a limited and focused
physical examination is performed. In psychiatric
practice, greater emphasis is usually placed on the type
and severity of the patient’s symptoms than on physical
findings.
 Case History
i. General
vital signs like
➢ Blood pressure
➢ Pulse
➢ Respiratory rate
➢ Temperature
ii. Systemic
➢ Skin
➢ HEENT (head, eyes, ears, nose and throat)
➢ Pulmonary (lungs/thorax, slight cracks at the right and left lobes)
➢ Cardiovascular system (no murmurs (a low continuous background noise ), S1 (the first heart sound in
the cardiac cycle, occurring at the outset of ventricular systole)+S2 (the second heart sound in the cardiac
cycle. It is associated with closure of the aortic and pulmonic valves at the outset of ventricular diastole. The
second sound is louder and shorter than the first) audible)
➢ Abdomen
➢ Genito-urinary tract
➢ Musculo-Skeletal and Extremities e.g. pedal edema (the accumulation of fluid in the feet and
lower legs. It is typically caused by one of two mechanisms, venous edema, lymphatic edema) (MS/Ext)
 Case History
➢ Neurologic (Neuro)
• Laboratory test (Lab: test)
Various lab-test are performed that help in diagnosis. Therefore
a health care provider should having the knowledge of these
lab-test and also about their ‘reference range’. The important
lab test performed are
➢ Hematological test
• RBCs
• Hb
• ESR
• PCV (packed cell volume)- (measurement of the proportion of blood that is made up
of cells. The value is expressed as a percentage or fraction of cells in blood. For example, a PCV of 40%
means that there are 40 millilitres of cells in 100 millilitres of blood)
• MCV (mean corpuscular volume)- (measure of the average volume of a red
blood corpuscle-RBCs)- (In patients with anemia, it is the MCV measurement that allows
classification as either a microcytic anemia (MCV below normal range), normocytic anemia (MCV
within normal range) or macrocytic anemia (MCV above normal range))
 Case History
• MCH meancorpuscular haemoglobin (average mass of hemoglobin per red blood cell in a sample of blood. It is
reported as part of a standard complete blood coun)
• WBCs
• TLCs total leucocyte count (A high white blood cell count usually indicates: An increased production of
whiteblood cells to fight an infection. ... A disease of bone marrow, causing abnormally high production of
white blood cells. An immune system disorder that increases white blood cell production)
• DLC differential leucocyte count –( measures the percentage of every single type of WBCs in the body.
There are five types of normal WBCs in the blood. Their respective normal range in adults is as follows:
• Neutrophils or Polymorphs: 40 - 60%
• Lymphocytes (B and T cells): 20 - 40%
• Monocytes: 2 - 8%
• Eosinophils: 1 - 4%
• Basophils: 0.5 - 1%)
o Lymphocytes
o Neutrophil
o Eosinophil
o Monocytes
o Basophils
• INR (international normalize ratio)- ( a laboratory measurement of how long it takes blood to form a clot. It is used to
determine the effects of oral anticoagulants on the clotting system )
• PT (Prothrombin time)- (a blood test that measures how long it takes blood to clot. A prothrombin time test can be used to
check for bleeding problems. PT is also used to check whether medicine to prevent blood clots is working. A PT test may also be called an
INR test)
• APPT (activated partial Prothrombin time)
 Case History
• PLT (Platelet count)
➢ Liver function test’s
• Bilirubin total
• Direct / conjugated Bilirubin
• ALT/SGPT (Alanine transaminase / Serum glutamate
pyruvate transaminase)
• AST/SGOT (Alanine amino transferase/ Serum glutamic
oxalo acetic transaminase)
• ALP (Alkaline phosphatase)
• GGT (Gama glutamyl transferase)
• Albumin
• Globulin etc
 Case History
➢ Renal function test (RFTs)
• Blood urea nitrogen (BUN)
• Serum Creatinine (Scr)
• Creatinine Clearance (Clcr)
➢ Hepatitis test
• Hep-A
• Hep-B (HBs)
• Hep-C (HCV)
➢ Blood glucose test
• Fasting blood glucose (FBS)
• Random blood glucose (RBS)
 Case History
➢ Electrolytes
• Sodium (Na)
• Chlorine (Cl)
• Potassium (K)
• Calcium (Ca)
• Magnesium (Mg)
• Phosphate (PO4)
• HCO3 etc
 Case History
➢ Other relevant test;
• X-ray
• Electro cardiograph/gram (ECG)
• Ultra sound (U/S)
• Computed Tomography scan (CT-Scan)
• Magnetic Resonance Imaging (MRI)
• Diagnosis;
It is the Greek word foe knowledge. It is the process of
identifying a disease OR disorder in a person by
examining the person and studying the result of medical
test.
 Case History
Diagnosis begins when the patient is presented to the
doctor with a set of symptoms OR perceived (become aware)
abnormalities (such as pain, nausea, fever OR other
untoward feeling). Often diagnosis is relatively simple
and the physician can arrive at a clinical conclusion and
prescribe the proper treatment. At other times the
symptoms may be subtle (small but important) and
seemingly (apparently), making the diagnosis difficult to
finalize and requiring laboratory work.
The diagnosis is based on data, obtained by physician
from three sources,
• Patient’s: include the patient’s perception (observation,
awareness, opinion) of his OR her symptoms, medical
Hx, family Hx, Occupation and relevant facts.
 Case History
• Second set of information obtained from physical
examination of patients.
• Data obtained from medical test (Blood test, X-ray, ECG)
• Treatment at hospital
It consist all those drugs which are prescribed to the
patient after admission/ visit of hospital and during stay in
hospital.
It consist of
• Start date
• Dosage form
• Brand (Generic ) name of drug
 Case History
• Dose
• Route of administration
• Frequency
• Duration
• Stop date
. Daily progressing report (DPR)/Daily monitoring report
(DMR)
A daily monitoring report should be recorded on daily
basis, in order to monitor patient response to the
medication therapy. It is important for a clinical
pharmacist to monitor the following parameters.
 Case History
• Temperature (FO)
• Blood pressure (mm hg)
• Pulse rate (per min)
• Respiratory rate (per min)
• Response to therapy (+, -, 0)
• ADRs/Toxicities (Yes/No)
• Compliance
• Lab test results are also recorded.
. Discharge Medication
It consist of medicines which are listed on patient
discharge sheet for use in home after hospital discharge.
 Case History
Pharmacist also educate and counseled the patient about the
discharge medications. It consist of
• Dosage form
• Brand (Generic)
• Dose
• ROA (route of adm.)
• Frequency
• Duration
• Advice/Remarks
• Others