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Case study format

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format of case study : a Nursing point of view. it includes all the headings or points about which the information regarding the patient needs to be collected and helps to write a detailed case study

Publié dans : Santé & Médecine
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Case study format

  1. 1. Case study Demographic data:Name:Age:Gender:I.P. D No.:Ward:Address:Education:Occupation:Marital status :Religion:Date of admission:Name of the surgery:Type of anesthesia:Allergic to:Date of discharge:Brief socioeconomic history       Family history:Health status of family members:Total income:Dietary habits:Housing condition:Inter personal relationship:- Personal history  Personal hygiene: History of allergy: History of past illness:-
  2. 2.  History of present illness:Vital signs Temp: pulse: Head to toe examination General appearance     Body type:Posture:Gait:Activity:- Vital signs     Temperature:Pulse:Respiration:Blood pressure:- Height and weight Integument Skin:  Colour: Moisture: Temperature: Texture: Turgor: Vascularity: Lesions:Hair and scalp:  Distribution: Colour: Appearance: Scalp: Hair follicles:Nails:  Color: Thickness: Shape:Head And Neck resp: B.P:
  3. 3. Head:  Position:Eyes:           Position and alignment:Eyebrows:Eyelids:Lacrimal ducts:Conjunctiva:Sclera:Cornea:Pupil:Lens:Visual acuity:- Ears:  Auricles: Ear drum: Hearing acquity:Nose:      External nares:Mucosa:Discharge:Nasal septum:Sinuses:- Mouth and pharynx:        Lips:Mucosa:Gums:Teeth:Tongue:Palate:Pharynx:- Neck:  Neck muscles: Lymph nodes:-
  4. 4.  Thyroid gland: Trachea:Thorax And Lungs Posterior thorax:        Contour:Intercostal spaces:Rhythm of breathing:Thoracic muscles:Fremitus:Percussion:Auscultation:- Anterior thorax:     Thoracic muscles:Fremitus:Percussion:Auscultation:- Lateral thorax:  Percussion:Heart     Inspection:Palpation:Auscultation:Heart rate:- Breast  Inspection: Nipple: Palpation:Abdomen     Inspection:Palpation:Percussion:Auscultation:- Genitalia (Female)
  5. 5.     Labia majora:Labia minora:Urethral orifice:Vaginal orifice:- Genitalia (Male)  Penis: Scrotum: Inguinal ring and canal:Rectum And Anus  Inspection: Digital palpation:Musculoskeletal System     Inspection:Palpation:Range of motion:Muscle tone and strength:- Neurological System  Level of consciousness: Behavior: Cranial nerve function:Reflexes:  Biceps: Triceps: Patellar: Achilles: Plantar: Gluteal: Abdominal:Assessment Subjective data:Objective data:- Investigations
  6. 6. Patient’s value S.No. Name of investigation Normal value Doctor’s order Doctor’s Order S.No. Purpose Case in detail         Introduction Definition Etiology Pathophysiology Clinical manifestations Diagnostic findings Surgical management Nursing management Nursing care plan :Assessment Subjective data Objective data Nursing diagnosis Goal Planning Rationale Implementation Evaluation
  7. 7. Health education:S.No. Date Topic Nurse’s record :Date Recording Signature

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