CASE STUDY

1 Patient Bio-data
 Name: __________________________________________________________________
 OPD No: ________________________________________________________________
 IPD No:_________________________________________________________________
 Age/Sex: ________________________________________________________________
 Address:_________________________________________________________________
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 Marital Status: ____________________________________________________________
 Educational Status: ________________________________________________________
 Occupation_______________________________________________________________
 Family Income: ___________________________________________________________
 Source Of Health Care:_____________________________________________________
 Admission Date: __________________________________________________________
 Discharge Date: ___________________________________________________________
 Consulting Dr.: ___________________________________________________________
 Diagnosis: _______________________________________________________________
 Name of Surgery: _________________________________________________________
 Date of Surgery :__________________________________________________________

2 Chief Complaints with duration:-

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3. History of present illness:-
Onset: ________________________________________________________________________

Precipitating Factors: ____________________________________________________________

Elevating factors: _______________________________________________________________

Treatment Taken: ______________________________________________________________

Any Other:_____________________________________________________________________

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4. History of past illness

Acute infectious diseases: _________________________________________________________

Immunization: __________________________________________________________________

Previous Operation: ______________________________________________________________

Hospitalization: _________________________________________________________________

Injuries:________________________________________________________________________

Acute & Chronic illness:___________________________________________________________

Any Other:______________________________________________________________________

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5. History of allergy/
sensitivity:__________________________________________________________________
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6. Family History : Family Tree:

Type: ________________________________________________________________________

History of any illness: ____________________________________________________________

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7. Health facility near home

Type: ________________________________________________________________________
Distance: ____________________________________________________________________
Transport facility: _____________________________________________________________

8. Environmental History:
Housing : ___________________________________________________________________
Toilet : _____________________________________________________________________
Electricity: __________________________________________________________________
Drinking water: ______________________________________________________________
Drainage system & surrounding: _________________________________________________

9. Personal Hygiene:

Oral Hygiene: Frequency________________________ Agent_________________________

Bath: Per day/ Frequency _________________________Agent________________________

10. Diet:

Vegetarian/Non vegetarian:____________________________________________________

No. of meals per day: ________________________________________________________

Food preference: ____________________________________________________________

Food Avoided (if yes give reason)_______________________________________________

Fluid_____________________ glasses/ day

Tea & Coffee: _____________Cups/ day

Coldrinks _________________glasses/ day

11. Sleep & Rest:

Hours/ day:________________________________________________________________

Uninterrupted/ interrupted, explain: _____________________________________________

Drugs used for sleeping. If any (specify): _________________________________________

12. Elimination

Bowel per day: 1. Regular:_________ 2. Constipation:_______________________________

Frequency __________________________________________________________________

Urine frequency: During day _______________ Night _______________________________

13. Mobility & Exercise

Walking habits: 1. Yes 2. No.

If yes: Regular/ Irregular:_______________________________________________________

Exercise/ Activity: Sedentary, Mild, Moderate, Heavy:_______________________________

Joints: Pain, Discomfort, Restriction:______________________________________________

Any other: Specify_____________________________________________________________

14. Menstrual History:

1. Age of Menarche:___________________________________________________________

2. Age of Menopause:__________________________________________________________

3.Regular/ Irregular:____________________________________________________________

If Regular. Scanty, Heavy Cycle, Normal:__________________________________________

LMP_______________ Any other problem_________________________________________

15. Sexual & Marital History:

Spouse: General Health: Good, Fair, Bad:_________________________________________

Spouse Occupation: working, Non- working:_______________________________________

Relationship: Satisfactory, Unsatisfactory:_________________________________________

 Staying together: Yes, No:_____________________________________________________

No. of Children: Male;___________________, Female:_____________________________

16. General Health:

Handicaps/ Deficiency/ Impairment Prosthesis/ Implants/ Fixtures/ Aids

Specify_____________________________________________________________________

1. Hearing aids, 2 Contact lenses & specs, 3. Dentures, 4. Pacemaker, 5. Catheters & tubing,

6. Any other : Specify____________________________________________________________

17. Substance Use: Tobacco, Drugs, Alcohol, Any other

Specify____________________________

____________________________________________________________________________

Addiction: Yes, No. /if yes_______________________________________________________

18. Physical Assessment & Observation

General Appearance: __________________________________________________________

Sensorium: Unconscious, Conscious, Alert, Oriented, Confused: _______________________

Emotional State:______________________________________________________________

Foul Body Odour: Yes, No:____________________________________________________

Foul Breath: Yes, No:_________________________________________________________

19. Physical Examination

Height_____________________ Weight________________________

Temperature_________________ Pulse ________________________

Respiration__________________ BP___________________________

(Note: Complete physical examination of a system according to patient condition (Ex.

Diagnosis- Asthma, Respiratory system)
20. Description of Disease

(A) Introduction

(B) Definition

(C) Anatomy & Physiology

(D) Causes, Risk factors/Predisposing factors (Book & pt. picture)

S.NO According to Text Book In Patient

(E) Clinical features(Book & pt. picture)

S.NO According to Text Book In Patient

(F) Etiology and Pathophysiology (in detail)

Note- If the patient is having 2-3 diagnosis, all the diseases need to be explained.
21. Diagnostic tests and evaluation

According to Book
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Patient Picture

Date Investigations Done Normal Value with Unit Patient Value

 S.No. Date Diagnostic test/procedure Impression

22. Management: (Brief description)

S. No. According to Text Book Plan for patient

 23. Treatment
S.No. Drug Name(Trade Dose Route Frequency Action Side effect Nursing
& chemical name) Responsibility
24. Any other management (if surgery done)-

Type of Anesthesia (Brief):__________________________________________________

Pre & post operative diagnosis :______________________________________________

Brief description of surgery:_________________________________________________

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Post operative orders:_______________________________________________________

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25. Dietary Management (Daily):_______________________________________________

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26. Nursing Management: (If surgical case write pre & post operative care plans)
Nursing assessment

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27. Nursing care plan
S.No Assessment Nursing Diagnosis Goal Intervention Rationale Evaluation

Subjective Data

Objective Data
28. Daily Progress (Day by Day vitals, General condition, any nursing procedure done)

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29. Complications
S.No. According to Book Seen in Patient
30. Discharge Planning- (Health Education & Follow up)
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31. Conclusion:
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32. Bibliography:

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