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Case Presentation Format Revised

This document presents a case presentation template for a patient that includes sections for the patient's profile, history of illness, family history, personal history, lab investigations, physical examination, disease condition, nursing care plan, medication, health education, and discharge plan. The template provides guidelines for the type of information to include in each section, such as identification data, chief complaints, past medical/surgical history, diet, socioeconomic status, vital signs, and systems examined. It aims to guide nursing students in comprehensively documenting and presenting a case study of a patient.

Uploaded by

Antonio Liezeth Jane
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
105 views

Case Presentation Format Revised

This document presents a case presentation template for a patient that includes sections for the patient's profile, history of illness, family history, personal history, lab investigations, physical examination, disease condition, nursing care plan, medication, health education, and discharge plan. The template provides guidelines for the type of information to include in each section, such as identification data, chief complaints, past medical/surgical history, diet, socioeconomic status, vital signs, and systems examined. It aims to guide nursing students in comprehensively documenting and presenting a case study of a patient.

Uploaded by

Antonio Liezeth Jane
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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TANCHULING COLLEGE, INC.

College of Nursing
Imperial Court Subdivision, Phase II,
Legazpi City 4500 Philippines
Tel. # (052) 480-6106/(052) 742-0098
http://www.tanchuling.edu.ph

CASE PRESENTATION

Patient’s profile
1. Identification Data:
Client name: (OPTIONAL)
Age/sex:
Father/Spouse Name (OPTIONAL)
Hospital Registration number (OPTIONAL)
Ward
Bed No
Address
Education
Occupation
Marital Status
Religion
Date of Admission
Date of Discharge
Diagnosis:
Surgery (if any)
Date of Surgery

II. History of Illness


Chief complaints

Present medical history complaints of


dyspnea (complaints of dyspnoea, low blood
pressure and cold and clammy skin.

Present surgical history (complaints of


backache, low blood pressure, fever, etc

Past medical history: history of any


hypertension, Diabetes mellitus, asthma,
COPD or other
disease.

Past surgical history: history of any surgery in


the past.

Add Gordon’s Functional Pattern

(Please check the link to help you with your presentation of Gordon’s)

https://www.slideshare.net/ChingbooLaud/sample-gordons-functional-health-pattern-intestinal-obstruction-
powerpoint-presentation

1
FAMILY HISTORY

No. Family Members Age/Sex Occupation Relation to Health Status Eductational


Patient Attainment

Note: Please use initial for confidentiality

2
PERSONAL HISTORY

Dietary Habits (vegetarian/ non vegetarian)

Addiction: history of smoking, drug addiction,


alcohol consumption, etc.

Socio-economic status:

3
LAB INVESTIGATION

Investigation Name Normal Value Patient’s value Clinical significant


/indicators/Remarks

4
Physical Examination

General Appearance: Findings

Body built
Height
Weight
Vital signs: Temperature:
Pulse:
Respiration:
B.P:

Color of the skin

Head:
• Shape and size of skull:
• Scalp:
Face
Eyes:

Vision:
• Eye brow and eyelid:
• Eye ball:
• Conjunctiva:
• Sclera:
• Cornea and iris:
• Pupil:
• Lens:

Ear:
• External ear:
• Tympanic membrane:
• Hearing problem:

Nose:
• External nares:
• Nostrils:

Mouth and pharynx:


• Mouth:
• Teeth:
• Tongue:
• Throat and pharynx:

5
General Appearance: Findings

Neck:
• Thyroid gland:
• Lymph node:
• Range of motion:

Chest:
• Breath sounds:
• Lungs:
• Heart:

Abdomen:
• Inspection:
• Auscultation:
• Palpation:
• Percussion:

Extremities:
• Upper:
• Lower:

Back: assess redness, bed sores, etc.


Genital and rectum:
Systematic examination:
• Central nervous system:
• Sensory system:
• Respiratory system:
• Cardiovascular system:
• Gastro intestinal system:
• Musculoskeletal system:
• Genitourinary system:
• Integumentary system:

6
DISEASE CONDITION: (for e.g.- Cardiogenic Shock)
Definition:

Causes:

Sign and Symptoms:

Pathophysiology:

Diagnostic evaluation:

Ideal nursing care:

Rehabilitation:

7
NURSING CARE PLAN
Patient’s Nursing Diagnosis:
Age:
Date of Admission:

(see separate sheet)

8
MEDICATION

Name of Drug Dose/Route Classification Action Side effect Nursing


responsibilities

9
LAB INVESTIGATION

Investigation Name Patient Result Findings Clinical significant indicators

10
Health education:

Discharge plan:

Summary:

Bibliography:

Kaohsiung J Med Sci.,. 2008 Jul;24(7):356-60. doi: 10.1016/s1607-551x(08)70132-


3.https://pubmed.ncbi.nlm.nih.gov/18805750/

Prepared by:

Visitacion O. Bumalay, Ed.D. RN

Faculty, TCI

11

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