It is a report of patients disease progress including the information and reasoning behind diagnose and management decisions.
SIGNIFICANCE OF PATIENT PROFILE: the purpose of patient profile is to provide history of the patients previous medication include a note on idiosyncrasy, allergies, ADR’s together with a record of his current medication. This enable the practitioner and the pharmacist to monitor.
PARTS OF PATIENT HISTORY:
A patient profile has the following parts
1. PATIENT DETAIL:
A patient profile is conventionally prepared by a brief description of patient complain. The patient detail may contain following information,
NAME, AGE, SEX RACE, OCCUPATION, ADDRESS, WEIGHT, WARD NUMBER, MEDICAL RECORD NUMBER, DATE OF ADMISSION.
2. PATIENT COMPLAINTS
These are complaining that brought the patient to clinical setting. This complains should be listed and be written in chronological order.
3. HITORY OF PRESENT ILLNESS
Should be written in patients own language.
Ø Write in paragraph form
Ø Never ask leading questions
Ø Keep quiet and let the patient to speak
4. PAST MEDICAL HISTORY
CHILDHOOD HISTORY: birth history either the child is normal, premature or past mature or any disease of childhood.
Ø Immunization complete or incomplete
Ø Adolescence history of any medical problem from childhood to adult.
Ø Secondary sexual character’s in female
Ø Adulthood history includes accidents, trauma or any other -------------?
5. PAST SERGICAL HISTORY
Any surgical procedure done in past e.g. appendix.
6. MEDICATION HISTORY
Ø Current medication
Ø Self medication
Ø Oral contraceptive.
7. ALLERGIES
Any kind of allergies from drug or food.
8. FAMILY HISTORY
Because many diseases have a significant genetic transfer mechanism . like, cardiovascular disease hypertension , diabetes , anemia, etc
9. PERSONAL HISTORY
it includes ,
Ø Habits , addiction , smoking
Ø Sleep habits
Ø Dietary habits
10. SOCIAL ECONOMIC HISTORY
It is ask for selection of brand. It include domestic situation, mobility, surrounding, and financial status.
11. SOCIAL EXAMINATION
Examination is general as well as systemic
GENERAL EXAMINATION:
It include
Ø Temperature
Ø Pulse rate
Ø Respiratory rate
Ø Blood pressure
SYSTEMIC EXAMINATION:
It include
Ø Heart sound
Ø Chest examine
Ø Abdomen
Ø Allergy
Ø Light reflection
Ø Pupil reflection
12. INVESTIGATION
Ø X-ray
Ø CT scan
Ø MRI etc
BLOOD PROFILE:
Ø WBC’s
Ø RBC’s
Ø Hemoglobins
Ø CBC
Ø DLC
Ø Platelet count
ELECTROLYTE:
Ø Na+
Ø K+
Ø CA++
Ø CL- level
RENAL PROFILE:
Ø Urea
Ø Creatinine level
Ø Pus cell count in urine
HEPATIC PROFILE:
Ø Bilirubin
Ø ALK (alkaline)
13. DIAGNOSIS:
A diagnosis is usually cleared by this stage. Alternatively it will be Provisionally awaiting confirm a--------------------?if different possible diagnosis seem differential diagnosis is resolve by further investigation.
14. MANAGEMENT
Each history should include with management plan. Management should be according to diagnosis. Personal involve our physician, nurses and pharmacist.
By Zeeshaan Ali (The University Of Lahore)
