Case study format
Name of patient:__________________________________________________________
Hospital No:______________________________________________________________
Date of hospitalization:_____________________________________________________
Duration of hospitalization:__________________________________________________
Patient Demographic Data (1 Mark)
Age:____________________________________________________________________
Address:_________________________________________________________________
Occupation:______________________________________________________________
Level of education:_________________________________________________________
Nationality:________________________Religion_________________________________
Marital status:_____________________________________________________________
Medical Data
Diagnosis:_______________________________________________________________
_______________________________________________________________________
Preoperative patient:______________________________________________________
Postoperative patient:_____________________________________________________
Name of operation:_______________________________________________________
Postoperative duration:___________________________________________________
Health History (1 Mark)
Chief complaints:___________________________________________________________
_________________________________________________________________________
Duration:_________________________________________________________________
History of present illness:____________________________________________________
_________________________________________________________________________
_________________________________________________________________________
__________________________________________________________________________
References (According to APA Format)
If it is a book it is listed in this way: author, year, Title, Edition, Place, publisher, Chapter &
page number.
Evans, C, and Tippins , E, 2008, foundations of nursing ,1st edition, published by McGraw –
Hill Education, Chapter 15 First Aid Knowledge and Skills ,PP: 315-316.
If it is a journal then it is listed in this way :Author ,Year, Article Title, Journal name, Edition
,Version , & page number.
Mohanan, K, Kaur, S, Das, K ,and Bhalla ,A ,2010, patient satisfaction regarding nursing
care at Emergency out patient department in a tertiary care Hospital,
Journal Of Mental Health & Human Behavior, vol. 15 No. (1), PP:54-58.
1.
2.
3.
Name of student:___________________________________________________________
Student No:____________________________ Group______________________________
Class:_____________________________________________________________________
Date of Submission:_____________________ Date:_______________________________
Signature of student:________________________________________________________
Teacher’s Evaluation Report
Total mark: 50
Total Marks Obtained:________________________________________________________
Signature of the Teacher:______________________________________________________
Date:______________________________________________________________________
Past Medical History (2 Marks)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Definition of the Disease (1 Mark)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Alteration/s in the Affected System (Pathophysiology) (5 Marks)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Etiology of Disease (5 Marks)
Serial According to the literature/Books In your patient
No.
Clinical Manifestation of the Disease (5 Marks)
Serial According to the literature/Books In your patient
No.
Investigations Conducted for Your Patient (2.5 Marks)
Name of Date Results Normal range Significance of the results
investigation
Treatment Carried Out for your Patient (2.5 Marks)
A. Medical
1. pharmacological
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
2. Non pharmacological
__________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
B. Surgical
___________________________________________________________________________
___________________________________________________________________________
Medical Treatment (5 Marks)
Name of Classification Dose Route frequency Action Possible Nursing
Drug (0.5 M) (0.5 M) (1.5 M) side responsibilities
effect (1.5 M)
(1 M)
Name of Classification Dose Route frequency Action Possible Nursing
Drug (0.5 M) (0.5 M) (1.5 M) side responsibilities
effect (1.5 M)
(1 M)
Nursing care plan (15 Marks)
Include at least one actual and potential nursing diagnosis
Nursing diagnosis Goals (2 Marks) Nursing orders/ Rationale Outcome criteria
(3 Marks) Interventions (3 Marks) (2 Marks)
(5 Marks)
Nursing diagnosis Goals (2 Marks) Nursing orders/ Rationale Outcome criteria
(3 Marks) Interventions (3 Marks) (2 Marks)
(5 Marks)
Discharge Plan (5 Marks)
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