PATIENT PROFILE FORM

DEPARTMENT OF PHARMACY PRACTICE, NGSMIPS

K.S. HEGDE HOSPITAL, DERALAKATTE

PATIENT NAME: X HOSP. NO: 16044759 DATE OF ADMISSION:30/8/2016

DATE OF DISCHARGE:
AGE: 6 yrs WEIGHT: 18.5 kg SEX: Male

COMPLAINTS ON ADMISSION: {Restlessness, temper tantrums, decreased sleep}x increased since 2 months,
Less response to name, speech delayed

MEDICAL HISTORY: History of mental illness since past 3 years and was on medication but it was discontinued.
MEDICATION HISTORY: SYP.RISPERIDONE

PERSONAL HISTORY: Problem started when he was 3yrs old, Mother was 40yrs old when she delivered him, has
chemical exposure to endosulphan.
FAMI LY HISTORY:` NAD
PREVIOUS ALLERGIES: NAD

PHYSICAL EXAMINATION
VITAL SIGNS:BP: 110/70 mmHg, PR:88 b/m
1. MENTAL STATUS EXAMINATION: PMA++ , ETEC-NO
SPEECH: amount & volume decreased, tone & tempo increased
THOUGHT: could not assessed
MOOD: irritable
PERCEPTION: couldnt assessed
CONGENITAL FUNCTION : unable to hold his attention,
Poor concentration
CONNERS AABREVATED RATING SCALE :
Short attention span, restlessness ,excitable ,easily frustrated, poor eye contact
Lack of social reciprocity, disturb other children, mood change quickly, temper tantrums

3.VINELAND SOCIAL MATURITY SCALE: WHICH INDICATES MODERATE

MENTAL RETARDATION

2. PROVISIONAL DIAGNOSIS : hyperkinetic disorder-disturbances of activity-attention

Pervasive developmental disorder-mental retardation &
stereotyped movement

LAB INVESTIGATION: nil

,
FINAL DIAGNOSIS: ADHD , AUTISM
 DRUG TREATMENT CHART:

Sl. GENERIC BRAND FREQ DOSE ROUTE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

no NAME NAME
1 RISPERIDONE SIZODON 8-0-8 0.25mg Oral
(oral solution) 0-0-8 0.25mg Oral
4-4-8 0.25mg Oral
0-0-8 0.25mg Oral

2 T.METHYLPHENIDA-
methylph 1-0-0 10mg Oral
TE enidate 1-0-0 15mg Oral
1-1/2-0 10mg Oral

PROGRESSION CHART
DAYS PROGRESSION
1 Restlessness, decreased sleep, irritability. Running around in the ward from the morning.
BP:110/70mmHg, PR:82b/m. DRUG: oral solution risperidon

2 Sleep-better, appetite-N, continue to move around restless in the ward, not very disruptive
BP: 120/80 mmHg, PR: 82b/m. new DRUG: Tablet. Methylphenidate.

3 Mother reported pt slept well, over activity came down, appetite :N

BP:110/80 ,PR:84b/m

4 Sleep adequate ,appetite: N

BP:110/70mmHg , PR:82b/m

5 Fever reported with chills & cough ,nasal congestion ,no joint pain, sleep: adequate ,appetite: N
BP: 110/84mmHg, PR: 78b/m. DRUG: Oral solution RISPERIDONE-frequency changed to once a day 8drop,
T.METHYLPHENIDATE- dose changed to 15mg.
DAYS PROGRESSION
6 Fever, Sleep :adequate, Appetite :N, restlessness reduced
BP:130/70mmHg, PR:88b/m
DRUG: oral solution risperidone-frequency changed

7 Sleep N, Appetite N, BP: 110/80 mmHg, PR: 84b/m.

8 Sleep N, Appetite N , BP: 120/90 mmHg, PR: 79 b/m

9 Sleep N, Appetite N, BP:130/70 mmHg, PR: 80b/m

DRUG: oral solution risperidone-frequency changed

10 Sleep: adequate, restlessness reduced; start to speak few words comprehensively.

BP:110/70 mmHg, PR: 82b/m

11 Sleep N, Appetite N, BP: 110/80mmhg, PR: 78b/m.

Speech therapy provided .DRUG: T.Methylphenidate frequency& dose changed to 10mg

12 Sleep N, Appetite N. BP: 110/80mmhg.PR:80b/m

13 Sleep N, Appetite N. BP: 110/90mmhg, PR: 82b/m.

speech therapy provided

14 Sleep N, Appetite N, BP: 110/80mmhg, PR: 80b/m.

Speech improved after speech therapy.

15 Sleep N, Appetite N. BP: 100/80mmhg, PR: 81b/m.

Speech therapy provided