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Division of Nursing Education CASE STUDY

1- Biographic data . Name . Age . Address . Date of admission . Source of referral 2- Personal and social history . Educational back ground . Marital status . Ability to meet specific need . work / social history 3- Mental status . Language . Concept of time / space / causality /nature . posture . memory . personal appearance . behavior during interview 4- General health status Activities of daily living ( exercise / rest / sleep ) Nutrition pattern (appetite / weight / eating pattern elimination pattern 5- Present illness . chief complaints . date of onset . character of complaints . mode of onset , course and duration . location . pathophysiology of disease Relationship to other symptoms , body function system . past medical / surgical history 6- Treatment . Medical treatment / Medication . Investigation / Procedure . Nursing diagnosis / problems/ NCP

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