FORMAT FOR CASE STUDY
INTRODUCTION
NAME OF THE PATIENT: NAME OF STUDENT:
AGE: SEX DATE OF DATA
COLLECTION
DATE OF ADMISSION: REGISTRATION NO.
ADDRESS:
RELIGION: MARITAL STATUS
EDUCATION:
FAMILY INCOME:
PROVISIONAL DIAGNOSIS
OPERATION DONE DATE OF OPERATION
ADMISSION NOTE: Received the patient from OPD /Casualty /Emergency /Home/ Other
Walking/on stretcher/ wheel chair conscious/semiconscious/unconscious
PRESENTING COMPLAINTS: Describe the complaints with which the patient has come to
hospital
HISTORY OF PRESENT ILLNESS: (description of symptoms including
onset location duration quality intensity aggravating alleviating and associated factors, course
of illness and problem)
PAST-MEDICAL HISTORY: (summary of patient's health including major and minor
illnesses, previous hospitalization and surgery, major injuries or accidents, drug, food
allergies, usual response to illness)
SOCIO ECONOMIC STATUS: (accommodation, No. of members living in the family, living
environment, monthly family income, recreation, religious practices, role relationship etc).
Family Tree: Three generation family tree
Pedigree keys:
Male
○ Female
− Relationship
Died
○ Patient
Family composition :
[Link] Name of Age/sex Relationship education occupation Income Health
the with head of status
family the family
members
MEDICATION HISTORY: (listing of medications including name, dosage, frequency of
administration, duration of therapy, time of last dose)
HABITS:( (smoking, alcohol, tobacco etc. Description of usual pattern of usage including
alcohol type, average consumption, amount per day, age started/stopped)
FAMILY HISTORY OF ANY ILLNESS:( (identification of family members and health
trends, health status of living members, age, sex and cause of death of deceased family
members, family history of cancer, heart disease, hypertension, stroke, epilepsy, renal
disorders, diabetes, arthritis, tuberculosis, HIV/AIDS)
FUNCTIONAL HEALTH PATTERNS:
[Link] PERCEPTION AND HEALTH MANAGEMENT PATTERN:
[Link]/ METABOLIC: (veg/ non veg,meal pattern, any practices)
[Link]-EXERCISE
[Link]/ REST :
[Link] PATTERN:( (bowel and bladder habits, problems in micturition,
constipation, diarrhea etc)
[Link] PRACTICES:
[Link]/ PERCEPTUAL:(includes the adequacy of sensory modes such as
vision, hearing, taste, touch or smell and the use of prosthetics for disturbances; in addition
to the
cognitive functional abilities such as language, memory decision making are included)
8. SELF PERCEPTION SELF CONCEPT PATTERN: (includes individual attitudes about
himself for herself. perception of abilities, body image, identity and general sense of worth
and general emotional pattern; pattern of body posture and movement, eye contact, voice and
speech pattern)
9. Physical examination
Height
Weight
BMI
GENERAL APPEARANCE:
Body built
Posture and gait
Body movements
Consciousness
Nourishment
VITAL SIGNS
Temperature
Pulse
Respiration
Blood pressure
Spo2
POSTURE
Body curve
Movement
MENTAL STATUS
Conscious level
Orientation
Head to foot examination
Head and face
Skull
Scalp
Hair
Forehead
Face
Skin & Nail
Colour and vascularity
Temperature
Texture
Turgor
Edema
Lesion
Nails
EYES
Eye brows
Eye lids
Eye lashes
Sclera
Conjunctiva
Cornea
Pupils
Eye movement
Vision
EARS
Tympanic membrane
External ear
Internal ear
Hearing
NOSE
Size and shape
External masses
Nostril
Septum
Nasal mucosa
MOUTH AND PHARYNX
Lips
Teeth
Gums
Buccal mucosa
Tongue
Tonsils
NECK
Thyroid
Lymph node
Movements
CHEST:
Thorax
Breath sound
Lung sounds
Heart sounds
Breast or nipple enlargement /tenderness
Abdomen
Inspection
Auscultation
Palpation
Percussion
EXTREMITIES
Lower extremities
Upper extremities
SPINE AND BACK
Spinal curvature
ROM
10. Disease condition
I. Definition
II. Incidence
III. Related anatomy &physiology
IV. Etiology and risk factor of disease condition /predisposing factor
Etiology and risk factor Description of causes of
present in book patient
V. Pathophysiology
VI. Clinical features of the disease condition
Clinical features present Description of clinical
in book features of patient
VII. Medical/surgical management
Aim of management
Management
12.
DAT NAME OF THE PATIENT NORMAL INFERENCE
E INVESTIGATIONS VALUE VALUE
Radiological examination
Other Investigations
Remarks
13. MEDICATIONS
[Link] Drug Pharmacol Route Dose & Action Side effects Nurses
trade ogical frequency & drug Responsibilit
name name interaction ies
14. LIST OFNURSING DIAGNOSIS ( as per NANDA diagnosis)
Assessment Nursing Objective Planning Rationale Implementatio Evaluation
Diagnosis n
Subjective data
&
Objective data
15. NURSE’S NOTE :
NAME OF THE HOSPITAL
NAME OF THE PATIENT: ________________ AGE: ________ IPD NO________
DOCTOR NAME ___________ WARD __________
DATE OF ADMISSION ____________ DIAGNOSIS____________ DATE OF
SURGERY IF ANY________
DATE/ TPR BP MEDICATION DIET OBSERVATION SIGNATURE
TIME & NURSING
CARE
16. DAY TO DAY PROGRESS REPORT
17. HEALTH EDUCATION
18. REFERENCES/BIBLIOGRAPHY