CASE STUDY / CASE PRESENTATION FORMAT

INTRODUCTION
As a part our clinical posting in ……………………………………………. hospital I
………………………………………… of ……. year BSc Nursing, got posted in
…………..…ward on …………..There I have selected Mr./Ms/Mrs
…………………………………….as my patient. He /she got admitted in hospital with the
chief
complaintsof……………………………………………………………………………………
……………………………. and diagnosed as …………………….……….. I have provided
all the possible nursing care and health education to the patient.
HISTORY COLLECTION
1. DEMOGRAPHIC DATA
 Name of the client :
 Age :
 Gender :
 I P No. :
 Address :
 Religion :
 Education :
 Occupation :
 Marital status :
 Date of admission :
 Date of care strated :
 Date of care ended :
 Medical diagnosis :

In surgical case,
 Surgery done :
 Date of surgery :
 Post operative day :
2. CHIEF COMPLAINTS ON ADMISSION:

Chief complaints during admission, reason for hospitalization, signs and symptoms, its
onset, duration &frequency. Investigations done on admission. Vitals at the time of
admission. Referred hospital, received doctor, and final diagnosis, patient status.

3. PRESENT MEDICAL HISTORY

Present complaints of the patient with provisional/final diagnosis. Investigations done

and planned. Symptoms; onset, duration, frequency, location, quality, and alleviating
or aggregating factors. Management done & planed

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 4. PRESENT SURGICAL HISTORY

Planned and performed surgical procedures during this admission. Name of the
procedure planned/done, time, duration, complications, performed by whom. Type of
anaesthesia, Surgical Notes.

5. PAST MEDICAL HISTORY

Illness: communicable and non-communicable diseases in the client’s life time.

Allergies: to drugs, animals, insects, other environmental agents, and the type of
reactions.

Accidents or injuries: how, when, and where, type, and treatment received for it.
Hospitalization: for serious illness, reasons, dates, recovery, and any complications
Medications: currently using, over the-counter medications.

6. PAST SURGICAL HISTORY

Past surgical history, diagnosis, procedure performed & its outcome, when it’s done,
complication developed if any, medications followed after the procedure, follow up
details, recovery.

7. FAMILY HISTORY
 Type of family : nuclear / joint
 Family medical history : case of any communicable /hereditary
disease / DM /HTN/IHD/cancer etc

S. Name of Age Gender Relatio Education Marital Occupatio Health

no family In n with status n status
members Yrs patient

GENOGRAM /FAMILY TREE: KEY:

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8. PERSONAL HISTORY
 Dietary pattern : vegetarian / mixed
 Likes & dislikes :
 Food allergies :
 Sleep pattern : normal /insomnia /parasomnias
 Bladder elimination pattern : normal / oliguria/polyuria /others
 Bowel elimination pattern : normal / diarrhea /constipation/others
 Hygiene/ADL :
 Hobbies :
 Habits :drug abuse/alcoholism/betel chewing/tobacco/other
substance abuse
9. MARITAL HISTORY
 Marital status : married/ single/divorced
 Type of marriage : consanguinous/non-consanguinous
 No of children :
10. MENSTRUAL HISTORY ( in case of female patients)
 Age of menarche : …..years
 Menstrual cycle : regular / irregular
 Any menstrual abnormalities : DUB / dysmennorhea /amennorhea
 Age of menopause :…..years / no

11. SOCIO ECONOMIC HISTORY

 Bread winner of the family : Mr. /Mrs.

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  Number of earning members :
 Monthly income : Rs. / month
 Type of house : own/rented. pucca /semi puccca /kacha
 Water facility : public tap / bore well /well
 Hospital/health care facility :

PHYSICAL EXAMINATION
GENERAL APPEARANCE
 Appearance : normal/diseased/anxious/dull/worried/tensed
 Body built : lean/moderately built/ well-built/obese
 Posture : straight/curved/scoliosis/kyphosis/lordosis
 Gait : steady/unsteady /bed ridden
 Grooming : well /moderate/poor
 Hygiene : hygienic /unhygienic
 ROM : possible/ partially possible/ restricted/painful ROM

MENTAL STATUS
Consciousness : conscious/ semiconscious/ unconscious
Orientation : orientation to time, place, and person
Mood : happy/ anxious/ stressed/ tensed/elated/ eastacy

BODY INDEX
 Height (in kg ) :
 Weight (in cms ) :
 BMI :

VITAL SIGNS
VITAL SIGNS NORMAL PATIENT
VALUE VALUE REMARKS

Temperature

Pulse

Respiration

Blood pressure

PAIN SCORE: ……………….

ASSESSMENT TOOL: VAS/ facet pain scale/ numerical pain scale/ verbalization/ others

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HEAD TO FOOT ASSESSMENT
HEAD
 Size : normocephalic/ microcephalic/ macrocephaly/ hydrocephalic
 Shape : symmetrical/asymmetrical/round/ oval
 Scalp & skull : lesions / lacerations /head injury/ abrasion/ fracture/ others
 Hair : equally distributed /alopecia/ uneven distribution
 Colour of hair : black/grey/ black & grey/ brownish
 Pediculosis : present /absent

FACE

 Shape : symmetrical/asymmetrical/round/ oval

 Temporomandibular joint: Intact/Dislocated

 Trigeminal nerve : Functionally intact/functionally distorted

 Facial nerve : Functionally intact/functionally distorted

EYES
 Position and alimentation : normal/deviation/abnormal profusion
 Eye brows : normal /scanty/ equally distributed
 Eye lashes : normal /sty /fallen/ scanty
 Eye lids : normal / edematous / drooped
 Cornea : whitish / yellowish /pale
 Iris : colour and shape
 Pupils (PERRLA) : reacting to light / not reacting, colour, shape, symmetry
of
size, reaction to accommodation
 Conjunctiva : pale /pink /reddish
 Sclera : whitish / yellow colour/red
 Eye movements : equal coordination /unequal
 Optic nerve : Functionally intact/functionally distorted
 Visual acuity : normal /myopia /hyper metropia /astigmatism /squint eye/others

EARS
 Pinnae : normal /located upwards /folded/ elasticity/tenderness
 Auditory canal : normal /obstructed /lesions/ pus/ blood
 Cerumen impaction : present /absent

 whisper test : positive / negative

 Weber’s test : positive / negative

 Rinne test : positive / negative

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 Hearing acuity : normal/deaf /partially deaf/by hearing aids
 Any abnormalities : pain /dizziness/ vertigo/tinnitus/drainage
 Vestibulocochlear nerve : Functionally intact/functionally distorted

NOSE
 External nose (Shape) : deviated/ symmetrical/asymmetrical/ flared
 Nasal septum : deviated /not deviated
 Nasal cavity : crusts/nasal polyps /lesions/mass/ discharges/ epistaxis/congestion
 Facial sinus : Pain / tenderness/ drainage
 Olfactory nerve : Functionally intact/functionally distorted

MOUTH & PHARYNX (GI SYSTEM)

 Lips : pink/moist/ intact skin/bluish/discoloured/ cracked
 Oral cavity : stomatitis / oral thrush/lesions/ pink/ reddish/ moist/dry/ others
 Gums : gingivitis / redness /normal/ infected /pus
 Teeth : evenly distributed/ dental carries/ artificial dentures/ ordour/
colour
 Dental hygiene : good /fair/poor/ hallitosis
 Tongue : normal /coated/ulcers/ discolouration/ moist /dry
 Mucous membrane : normal/reddish /pale /yellow
 Sense of taste :present /absent
 Uvula : position, mobility
 Oropharynx : colour, texture

 Facial/Glossopharyngeal nerve / Hypoglossal nerve/vagus: Functionally

intact/functionally distorted

NECK & THROAT

 Tonsils : enlarged /normal /painful /infection
 Lymph nodes : enlarged or not enlarged/ palpable or not palpable
 Thyroid gland : enlarged / not enlarged
 Jugular vein : distended /normal
 Throat : normal / sore throat /hoarseness /dysphagia /pain
 Stiffness of neck : present /absent

CHEST
• Size and shape of chest : symmetrical/ barrel chest/pigeon chest/ flial chest/ sub
diaphragmatic shift/ tracheal shift/ others
RESPIRATORY SYSTEM
 On inspection : normal( bilaterally symmetrical)/ asymmetrical chest Movements
Respiration : normal/ Dyspnea /orthopnea/bradypnea/tachypnea/labored

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 Respiratory rate : beats/min
Cough : absent /present (non productive/productive)
 On palpation : palpable mass present or absent/ tenderness/ pain/ tactile fremitus
 On percussion : no fluid thrill/ hemothorax/ pneymothorax/ chylothorax/
/ pleural effusion/ emphysema/ others
 On auscultation(lung sounds):normal/ wheezing /rales /stridors/crackles/ rhonchi/
others

CARDIO VASCULAR SYSTEM

 On inspection : colour, superficial pulsations/ palpitations/ other observations
 On palpation : masses/ tenderness/ pulsations/ peripheral pulsation/carotid
artery/
jugular vein distension/ apical pulse
Chest pain : present /absent
Capillary refill : ……sec , (brisk/ rapid /sluggish)
 On percussion : heart size & borders/ pericardial effusion
 On auscultation
Heart rate : …..beats/min, (bradycardia/tachycardia)
Rhythm : regular/sinus tachycardia A Fib/ atrial flitter/ SVT/ v Fib/VT
Sinus bradycardia/ conduction blocks/PVCs/ others

Pulse :regular /weak /steady /strong /bounding/ feeble/

Heart sounds : normal S1 & S2 /S3 /S4/ murmurs /gallops/mitral click/others
Blood pressure : normal /hypotension/ hypertension

ABDOMEN
GASTRO INTESTINAL SYSTEM
 On inspection
Shape :flat /round /pendulous/ distended
Colour & texture : normal skin colour/ discolouration/ dry/ moist
Skin integrity : normal/ ascities/ stretch marks/ scar/ lesions/ abrasions
 On palpation : soft /hard/tender/ non tender/mass/ hepatomegaly/spleenomegaly
 On auscultation (bowel sounds): normal/ hyperactive BS/hypoactive BS/ absent BS
 On percussion : tympany/ dullness/ resonance/ flat/ hyper resonance
 Appetite : normal /anorexia/ bulimia nervosa
 Feeding : oral /NG tube /gastrostomy /jejunostomy/ PEG
 Bowel Elimination pattern : normal ( per rectum)/ colostomy
 Anus/rectum : anal fissure/ fistula/ hemorrhoids/ skin tags/ lesions/mass

GENITO URINARY SYSTEM

 On Inspection : hair distribution, infestations, inflammation, swelling, or lesions, any
discharges, orifices openings

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  On Palpation : lymph node enlargement, glandular enlargement

 Urine output / day : …………litres

 Micturation : normal/dysuria /polyuria /anuria
 Incontinence : present /absent
 Any abnormalities : UTI / kidney disorders /absent

NEUROLOGICAL ASSESSMENT
 LOC : alert /confused /sedated /somnolent
 Orientation : well oriented /moderately / poorly
 Communication : good/poor
 Speech : clear /unclear /sluggish
 Motor functions : steady /unsteady /weak
 Reflexes

Plantar reflex : Present/Absent

Biceps reflex : Present/Absent
Brachioradialis reflex : Present/Absent
Extensor digitorum reflex : Present/Absent
Triceps reflex : Present/Absent
Patellar/ knee-jerk reflex : Present/Absent

Ankle jerk/ Achilles reflex : Present/Absent

MUSCULOSKELETAL SYSTEM
UPPER EXTREMITIES

 Symmetry : equal or unequal

 Shape : oedema, swelling, deformity

 Muscle contraction : movable or contracture, tremor

 Muscle strength : equal or unequal (grade accordingly)

 ROM : possible/ partially possible/ not possible / moves

freely/painful

LOWER EXTREMITIES

 Symmetry : equal or unequal

 Shape : oedema, swelling, deformity

 Muscle contraction : movable or contracture, tremor

 Muscle strength : equal or unequal (grade accordingly)

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  ROM : possible/ partially possible/ not possible/ moves
freely/painful

 Spine curvature : normal/kyphosis/lordosis/scoliosis

 size and contour of the joint :normal/deformities/swelling/redness

INTEGUMENTARY SYSTEM
 Colour of skin :normal / pink/yellowish/pallor/erythema/cyanotic
 Hair distribution : equally distributed /alopecia/ uneven distribution
 Skin Texture : smooth / rough/ dry/ scaly/ moist
 Temperature :warm/cool and clammy /dry /moist
 Turgor :elastic/non elastic
 Vascularity : high /normal /low
 Edema : present(mention the location & type)/absent
 Lesions /scar : present(mention the location)/absent

FINDINGS / IMPRESSION
DISEASE PROCESS
 Definition
 Incidence & prevalence
 Review of Anatomy & physiology (with labelled diagram)
 Classification / types
 Etiology and risk factors (book picture & patient picture)
 Pathophysiology
 Clinical manifestations (book picture & patient picture)
 Diagnostic studies (book picture & patient picture)

INVESTIGATIONS
S. DATE NORMAL PATIENT
NO. INVESTIGATION VALUE VALUE REMARKS

OTHER DIAGNOSTIC INVESTIGATION:

MANAGEMENT
MEDICAL MANAGEMENT
 Medication orders
 Pre op / post op orders (in surgical case)
 Iv fluids/ colloids/TPN/ infusions/ transfusion if any
 Medication chart

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 Name Dose Rou Frequ Action Indication Contraindi Side Nurses
of the te ency cation effects resp.
drug

SURGICAL MANAGEMENT

Surgery – patient picture in detail

 Pre-operative care
 Surgery notes
 Post - operative care

DIETARY MANAGEMENT
 Diet plan for the patient (describe according to type of feeding)
OTHER MANAGEMENT (physiotherapy/ occupational therapy/ rehabilitation)
NURSING MANAGEMENT
 Problems identified according to priority
 Expected outcomes

LIST OF NURSING DAIGNOSIS (according to priority)

9 (care study/ case presentation)
write pre & post operative diagnosis in surgical cases as per the case selected
NURSING CAREPLAN (describe 7 care plan)
Assessment Nursing Planning Rationale Implementation Evaluation
diagnosis Goal
Subjective (three part
data: -NANDA
diagnosis)
Objective
data:

COMPLICATIONS (book picture & patient picture)

HEALTH EDUCATION:
 Diet
 Medication
 Exercise
 Follow up
 Personal hygiene

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  Infection control measure
 Special care(if any)

PROGRESS NOTE & DISCHARGE SUMMARY

DATE PROCEDURE SIGNATURE

Day 1-5 (care plan) Write about procedures,

investigations done, major finding,
Day 1-7 (CS/ CP)
progress of patient

Discharge summary (if discharged)

CONCLUSION
 Patient evaluation
 Self-evaluation

BIBLIOGRAPHY

NB: Include neat and labelled diagrams wherever necessary

Use appropriate AV aids for doing case presentation

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