COLLEGE OF NURSING

MAHARSHI VASHISTHA AUTONOMOUS STATE MEDICAL COLLEGE, BASTI

Case presentation/case
study
On

Topic:……..
Date of submission:

Submitted by: Submitted by:

Name Mr./Ms/Prof.
[Link]. Nursing 3rd Sem. Name
Batch: 2022-23 Designation
CON, MVASMC, Basti CON, MVASMC, Basti
 Care Study

HISTORY OF THE PATIENT

a) Identification Data -
Name :
Age :
IPD No :
Ward :
Bed No :
Address :
Religion :
Education :
Occupation :
Marital Status :
Date of Admission :
Diagnosis :
Consultant :
Chief complaints with duration :
FOR SURGERY PATIENTS - :
Name of surgery :
Date of surgery :
Date of care started :
Date of care ended :
Date of discharge :

b) Present medical history -

Mr/Mrs------------------got admitted in hospital on Date at time with the Chief
complaints of----------- x last from (days)
c)Past Medical History
Patient was having /not having past medical history of diseases of like -------------------------------------------------------
since -------------Years.
(Taking any medicine or not)

d)Past Surgical History

Patient does/does not have any significant past surgical history.
If have past surgical history - (name of surgery)/ Year of surgery any complications
after surgery.
e) Family History -
1. Family Tree Key:-
Female

Male

Name Age Name Age

Female Patient

Expired

Name Age Name Age Name Age Name Age

Male Patient

Name Age Name Age Name Age

2. Family Composition :
Name Age Sex Relation With Education Occupation Health
Patient Status

3. Family Health History :

There is no/there is history of congential/hereditary, communicable & psychiatric illness in the family.
There is history/no history of consanguineous marriage in the family.

f) HEALTH FACILITY NEAR HOME –

➢ Hospital / health center-
➢ Distance -
Transport facility etc
g) Nutritional Status
• Diet – Vegetarian/ Non/ Vegetarian
• Meals per day -
h) Personal History
➢ Oral hygiene: tooth paste / neem stick, Mode: brush / finger
➢ Bath : per day frequency…………….. Agent ……………….
➢ Diet: Veg / Egg / Non Veg.
➢ No of meals per day:……………………….
➢ Food preferences:………………………….
➢ Fluid:………...........glasses per day
➢ Tea & coffee : …………..Cups / day
 ➢ Sleep & rest :…………………hours / day

i) Socio – economic History :

➢ Housing – Type, Number of rooms etc
➢ Water supply – Tap / hand pump / any other
➢ Sanitation -
➢ Income – monthly/ annual
.
j) Environmental History :
• Environmental hygiene : maintained/ not maintained
• Disposal of waste :
• Water Supply : Tap water, Well, River
• Disposal of excreta : Sanitary Latrine, Open defecation.
k) Viral signs at the time of admission :

Sn Vital Signs Patient Value Normal Value Remarks

1 Temperature
2 Pulse
3 Respiration
4 B.P.

PHYSICAL EXAMINATION
Note : don’t write all & use of tick mark. Write patient condition specified term.
1. General Appearance

(a). Appearance : Cheerful/Anxious/distressed/sick

(b). Body Build : Thin/Moderate/Obese/emaciated
(c). Complexion : Fair/Dark/Whitish
(d) Nourishment : Well nourished/moderately nourished/malnourished
(e). Health Status : Healthy/Unhealthy
(f). Posture : Erect/any deviation/bed ridden
(g). Hygiene : Maintained/Not Maintained
(h). Speech : Clear/slurring/stammering/maintains eye contact
2. Mental Status-

(a). Behaviour : Normal/Active/Passive/Withdrawn/Hyperactive

(b). Orientation : Oriented to Time, Place, Person
(c). Level of Alertness : Alert/disoriented/lethargy/stupor/coma
(d) Emotional State : Happy/Sad/Crying/Anxious
(e). Intelligence : Good/Average/Poor
 (f). Judgment : Appropriate/Inappropriate
(g). Thought Process & Concentration : Attentive/Distracted
3. Anthropometric Measurements-
(a). Height .............................................................................................. Cm/Bedridden
(b). Weight .............................................................................................. Kg/Bedridden
(c). BMI ................................................................................................... Kg/M2
4. vital sign
(a). Temperature…………………..
(b). Pulse…………………………..
(c). Respiration…………………..
(d). Blood pressure……………..
5. Skin Conditions-
Colour : Pallor Jaundice, Cyanosis, Flushing
Texture : Dryness, Flatting, Wrinkling or Excessive Moisture
Temperature : Warm, Cold and Clammy
Lesions : Macules, Papules, Vesicles, Wound etc…….
Sensitivity : anesthesia, parasthesia, hypothesia, hyperthesia
Turgor : immediate/delayed
6. Nails-
Colour : pink/pale/cyanosed/ icteric
Texture : smooth/ brittle
Capillary refill : immediate/delayed
Nail bed : paronychia/clubbing/beau’s line/koilonychias/splinter
Hemorrhage
7. Head & Face
Size & Shape : microcephaly/Acromegaly/Hydrocephalus/Normal
Facial features : symmetrical/asymmetrical
Facial puffiness : present

8. Hair
Nature : Straight/curly/small/
Texture : dry/thin/oily/thick/healthy
Colour : flag sign/reddish/grey/black/brown
Distribution : equal/alopecia/baldness
Dandruff : yes/no

9. Eyes
Part/ Function Characteristics Right Eye Left Eye
 Eyebrows Symmetrical
Eye lashes • Infection
• Distribution of
lashes
Eyelids • Edema / Lesions /
Ectropion /
Entropion /
Ptosis
Eye balls Shape ( Protruded /
Sunken )
Conjunctiva Pink / Pallor /
Icteric /
Blue tinged

10. Ears :

a) Pinna : Normal/Small/Large/Present/Absent/Symmetrical/Asymmetrical
b) Placement : Normal(Anlog canthus line) Lowest
c) Discharge : Present/ No abnormal discharge like pus or blood seen
d) Cerumen (Wax) : Present/ no cerumen noted
e) Tympanic membrane : Normal/ perforated/ bulged
f) Hearing acuity : Normal/ impaired (Unilateral/ Bilateral)
11. Nose
a) Crust / Discharge : Present/ No abnormal discharge seen
b) Nasal septum : Normal/ Perforated / Deviated
c) Mucous membrane: Normal / Red in Colour
d) Polyps : Present / no polyp noted
e) Obstruction of the nose : Present/ No obstruction noted
12. Mouth and Pharynx :
a) Lips :Moist /dry/Cheilosis/Angular stomatitis.
b) Teeth : Normal/ Missed teeth/ loose teeth/ caries/ tartar/ plaque/ dentures.
c) Gum : Normal/ Red/ bleeding gums/ hypertrophied/ gingivitis.
d) Mucous membrane : Pink & moist / inflamed / cyanosed / ulcers/ leukoplakia /
Erythroplakia.
e) Throat : Normal / congested
f) Tonsils : Normal / enlarged / surgically removed / colour of tonsil / tonsillitis.
g) Breath odour : Normal / Halitosis / Acidotic / Fetor hepaticus / Alcoholic.

13. Neck :
 a) Lymph nodes : Palpable / Non palpable. ( If enlarged, specify the nodes).
b) Thyroid glands : Normal / Enlarged.
c) Jugular veins : Normal / distended.
d) Range of motion : Flexion / extension / hyperextension / rotation are possible / not
14. Chest & Lungs :
INSPECTION
a) Skin : Scar / lesions
b) Shape : Normal / Pigeon’s chest / Barrel chest / Flail chest.
c) Chest movement : Symmetrical / asymmetrical / chest retraction.
PALPATION
a) Vocal / tacile fremitus : Normal & symmetrical / faint / asymmetrical.
b) Tenderness : present / not noted. If present (area need to mention)
c) Mass : present / not noted. If present (area need to mention)
d) Temperature : warm / cold to touch
e) Chest expansion : symmetrical / asymmetrical
AUSCULTATION
a) Breath sound : Normal / Rhonchi / tachycardia (Beats / mt) / ectopic beat
b) Heart sound : s1 & s2 heard / abnormal heart sounds heard (type of sound need to mention) /
murmur
c) Heart rate : Normal / bradycardia / tachycardia (Beats / mt) ectopic beat
d) Rhythm : Regular / Irregular
e) Volume : Normal / bounding / weak &thread.
15. Breast :
a) Placement : Symmetrical / Asymmetrical
b) Size : Normal / atrophied / hypertrophied
c) Consistency : Soft / Nodular
16. Axilla :
a) Lymph nodes : Palpable / Not palpable
b) Hair : Present
17. Abdomen :
i. Inspection :
a) Skin : Rashesh / lesions / scars / discolorations / destended veins /
Telangiectasis.
b) Shape : Scaphoid / pendulous / flabby / distended
c) Abdominal girth :
ii. Auscultation :
Bowel sounds : heard / not heard
iii. Palpation :
 Soft &Non tender / hard / organomegaly (Hepatomegaly / splenomegaly), mass / tendernessAbdominal
thrill test.
iv. Percussion :
Tympany / hyper resonance / resonance / dull / flat.
18. Genitals :

a) Hair : Present / Absent

b) Lesions / mass : Present / Not seen
c) Scrotal swelling or masses : Present
d) Vaginal prolapse : Present / Not noted
e) Vaginal discharge : No abnormal discharge / bloody discharge with foul small /white
discharge
f) Congenital defects : No abnormalities / if yes Mention defects
g) Lymph nodes at inguinal region : Palpable / Non palpable

19. Rectum and anus : Bleeding / lesions / mass / cervix nodules / External hemorrhoids.

20. Musculo skeletal system

Upper Extremities Lower Extremities

Characteristics
Right Left Right Left
Muscle strength
Symmetry
Range of motion
(normal / limited)
Deformities
Use of mobility aids( walking
Stick, crutch / walker / calipers /
Wheel chair )

Coordination
Movements (coordinated / uncoordinated)Gait (
normal / unsteady)

21. Spine : Lordosis / Khyphosis / scoliosis

Reflexes Right Left

Biceps reflex Normal / hyper reflexia / Normal / hyper reflexia /
Hyporeflexia / areflexia areflexia
 Triceps reflex Normal / hyper reflexia / Normal / hyper reflexia /
Hyporeflexia / areflexia Areflexia
Patellar reflex Normal / hyper reflexia / Normal / hyper reflexia /
Hyporeflexia / areflexia Areflexia
Achillers reflex Normal / hyper reflexia / Normal / hyper reflexia /
Hyporeflexia / areflexia Areflexia
Plantar reflex Normal / hyper reflexia / Normal / hyper reflexia /
Hyporeflexia / areflexia Areflexia

IMPRESSION :

➢ LAB INVESTIGATIONS

Laboratory Tests/ Normal Range Patient Result Significance

Diagnostic Tests Findings/

➢ MEDICATION CHART

[Link] Name of the dosage Mode Route of Indication Contraindication Side Nursing
drug(Pharmacological of administration effects implication
& Trade name) action

➢ INTAKE OUTPUT CHART:

INTAKE OUT PUT
Date Time Parenteral Time Drainage Vomitous/ TOTAL
Oral RT Urine
Rout /suction Diarrhoea

O=
I=
B=

I= Intake, O=Output, B=Balance, RT= Ryle’s Tube feeding.

 DISEASE CONDITION
DIAGNOSIS:………………………..
Related anatomy & physiology
➢ Definition
➢ Etiology
Book picture Patient picture

➢ Path physiology
➢ Clinical manifestations
Book picture Patient picture

➢ Diagnostic evaluation
Book picture Patient picture

MANAGEMENT –

Medical management

Book picture Patient picture

➢ Surgical management :

Book picture Patient picture

➢ DIETARY MANAGEMENT:

➢ NURSING CARE PLAN :

 Nursing assessment Nursing diagnosis Planning Nursing Evaluation
Subjective/ objective implementation

Health education:-

Discharge planning:-

Bibliography:-