This document outlines the components that should be included in a patient profile. It discusses including patient details, presenting complaints, history of present and past illnesses, medication and allergy history, family history, examinations, investigations, diagnosis, and management plan. The purpose is to provide a history of the patient's condition and treatment to enable healthcare practitioners and pharmacists to monitor the patient's care.

1. Produced by: Dr.Sana Javed
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.

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

4. 1. 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)

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

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

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

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

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

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

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

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

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

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