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Case Study Format

This case study document contains a comprehensive medical history and examination of a patient, including their personal information, presenting complaints, medical history, family history, socioeconomic status, habits, physical examination findings, diagnosis of their condition, treatment plan, and nursing considerations. Sections include the patient's profile, history of present and past illness, physical assessment, description of their diagnosed disease, evaluation and management. Nursing aspects involve developing a care plan, applying relevant theories, prevention measures, health teaching, and concluding thoughts.

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DrPreeti Thakur Chouhan
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6K views12 pages

Case Study Format

This case study document contains a comprehensive medical history and examination of a patient, including their personal information, presenting complaints, medical history, family history, socioeconomic status, habits, physical examination findings, diagnosis of their condition, treatment plan, and nursing considerations. Sections include the patient's profile, history of present and past illness, physical assessment, description of their diagnosed disease, evaluation and management. Nursing aspects involve developing a care plan, applying relevant theories, prevention measures, health teaching, and concluding thoughts.

Uploaded by

DrPreeti Thakur Chouhan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CASE STUDY

PATIENT PROFILE
Name –
Age –
Gender –
Religion –
Marital Status –
Occupation –
Reg. No. –
Date of admission –
Ward –
Department –
Provisional Diagnosis –
Informant –

PRESENTING COMPLAINTS

HISTORY OF PRESENT ILLNESS

HISTORY OF PAST ILLNESS


Surgeries –
Allergies –
Medicine –
Immunization History –

FAMILY HISTORY
No. of members –
Types –
History of Illness –
Congenital problems –
Pedigree –

SOCIO ECONOMIC STATUS


Monthly Income –
Housing –
Sanitation –
Ventilation –

PSYCHOLOGICAL STATUS
Ethnic background –
Support System –

HABITS
Substance Use –
Diet –
Sleep –
Exercise –
Elimination –

PHYSICAL EXAMINATION
GENERAL APPEARANCE
Age –
Gender –
Nourishment –
Body build –
Gait –
Hygiene & Grooming –
Body Odor –
Activity –

MENTAL STATUS
Consciousness –
Look –
Mood –

POSTURE
Body Curves –
Movement –

HEIGHT –

WEIGHT –

VITAL SIGNS

Vital Signs Patient Value Normal Range


Temperature
Pulse
Respiration
Blood Pressure

SKIN CONDITION
Color –
Texture –
Temperature –
Lesions –
Turgor –
Condition of Nail –

HEAD & FACE


Scalp –
Face –
EYES
Eyebrows –
Eyelashes –
Eyelids –
Eyeballs –
Conjunctiva –
Sclera –
Vision -

EAR
External Ear –
Hearing –

MOUTH & PHARYNX


Lips –
Odor of Mouth –
Teeth –
Mucous membrane & gums –
Tongue –
Throat & Pharynx –

NECK
Lymph Nodes –
Thyroid Gland –
Range of Motions –

CHEST
Thorax –
Breath sounds –
Heart –
EXTREMITIES
Movement of Joints –
Clubbing of fingers –

BACK
Curves –

GENITAL & RECTUM


Inguinal lymph nodes –
Enlargement of Prostates –

NEUROLOGICAL TEST
Reflexes –
Test for sensations –

DISEASE CONDITION
I. DESCRIPTION OF THE DISEASE

II. ANATOMY AND PHYSIOLOGY

III. ETIOLOGY

S. No BOOK PICTURE PATIENT PICTURE


IV. PATHOPHYSIOLOGY

V. CLINICAL MANIFESTATION

S. No BOOK PICTURE PATIENT PICTURE

VI. DIAGNOSTIC EVALUATION

S. No BOOK PICTURE PATIENT PICTURE

Evaluation Result

VII. COMPLICATIONS

S. No BOOK PICTURE PATIENT PICTURE

VIII. MANAGEMENT

Medical management

S. No BOOK PICTURE PATIENT PICTURE


Surgical Management

S. No BOOK PICTURE PATIENT PICTURE

NURSING MANAGEMENT
NURSING CARE PLAN

Nursing
Assessment Planning Intervention Implementation Expected Outcome
Diagnosis
Subjective Data Short term
goals

Objective Data Long term goals


Nursing
Assessment Planning Intervention Implementation Expected Outcome
Diagnosis
Subjective Data Short term
goals

Objective Data Long term goals


Nursing
Assessment Planning Intervention Implementation Expected Outcome
Diagnosis
Subjective Data Short term
goals

Objective Data Long term goals


APPLICATION OF NURSING THEORY

PREVENTION MEASURES

HEALTH TEACHING

CONCLUSION
BIBLIOGRAPHY

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