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Case Study Question
Case Study Question
AGE: OCCUPATION:
GENDER: RELIGION:
ADDRESS:
CHIEF COMPLAINTS:
ATTENDING PHYSICIAN:
DIAGNOSIS/IMPRESSION:
Health History
I. Present Illness
Describe the onset of the problem
What was the setting or what was the patient doing at the time of onset?
Location
Quality
Quantity/severity
Immunizations received:
DPT
Measles
Mumps
BCG
Others
Adult illness.
Type
How treated?
Recovered or not?
Operations:
Injuries:
Allergies:
Current medications taken: (Including home remedies, non-prescription drugs, vitamin/mineral supplements and medicines
borrowed from family or friends. Asks about frequency and dosage.)
Diabetes
Tuberculosis
Arthritis
Anemia
Mental illness
Heart disease
Cancer
Alcoholism
Drug addiction
Smoker
Prenatal (Maternal health before or during pregnancy. Illnesses experienced by mother during pregnancy, complications, drugs
taken, duration of pregnancy.)
Natal (Nature of labor and delivery. Birth order. Birth weight. Complications during birth. Anthropometric data, Ballard scoring)
Neonatal (Onset of respirations, estimation of gestational age. Specific problem with feeding, respiratory distress, cyanosis,
jaundice, anemia, congenital anomalies, infection.)
V. Feeding History
Infancy.
Breastfeeding (frequency and duration of feedings, use of complimentary or supplementary artificial feedings, difficulties
encountered, timing and methods of weaning.)
Artificial feeding (Type of formula, concentration, amount and frequency of feeds, feeding difficulties, timing and method of
weaning. Vitamin supplements given.)
Supplementary feeding (types and amount of food given, when (age) introduced, infanot’s response.)
Physical growth:
Height
Weight at birth, ages 1, 2 5, and 10 years.
History of rapid or slow gains or losses in weight
Tooth eruption and loss pattern.
Developmental milestones: (Ages at which patient held up his head in prone position, rolled form front to back, sat with
support/alone, walked, said first word, combination of words, and sentences, tied own shoes, dressed without help.)
Social development:
Sleep patterns (amount and patterns during day and at night, bedtime routines, type of bed and its location, nightmares, terrors
and somnambulating)
Toilet training (age, methods used, difficulties encountered, terms used for defecation and urination).
Habits (head banging, thumb sucking, nail biting, pica, ritualistic behavior, tantrums, aggression, withdrawal)
Personality (degree of independence, relationship with parents/siblings, activities, and interests, special friends, major assets and
skills)
VII. Patterns of Functioning
Contour of chest
Palpation:
Percussion:
3. FOOD AND FLUID INTAKE General state of health Diet prescribed, fluids
prescribed, oral, parenteral,
Usual foods taken Body builds Results of GI tract x-rays,
liver function tests, blood
Nutritional state sugar level.
Meal pattern
How many meals does he take each day? Nutritional status of:
Skin:
poor skin turgor.
Time mildly dehydrated.
moderately dehydrated.
severely dehydrated.
Food allergies evenly distributed fine hair
Edema: pitting non-pitting
Eczema (scaling of the skin)
Food preferences and dislikes Dry skin
nausea
vomiting (Amount): _______
frequency: _______
loss of appetite
swallowing difficult
abdominal pain(scale 1-10): ____
dysphagia
9.COMMUNICATION AND SPECIAL EYE: distribution of lashes, condition of Results of sight and hearing
SENSES eyelids. Color of sclera, dryness or tests.
lacrimation. Characteristics of
Right handed left handed conjunctiva, pupils, eye control
Use of eye glasses movement, lens, presence of ulcerations,
Hearing aids abrasions, foreign body, eye infection,
For how long the patient is wearing growth, cataract
these? _______
Visual and auditory disturbances:
yes no
Speech disturbances:
yes no EARS: shape of pinna, legions, swelling,
Dialect or language spoken: _______ tenderness of mastoid process, external
canal, discharges, foreign bodies,
earache? Difficulty of hearing.
11. PAIN AND DISCOMFORT Facial grimace Check the physician’s record
for symptoms of which the
Pain and discomforts frequently guarding
patient complains.
experienced:
Pain scale (0-10): ____ Medications taken.
yes no
affect other patterns:
Describe manifestation: _________
yes no
Relief done: _____________
Discomfort felt:
Does he know the cause?
yes no
yes no
Describe: ______
Describe: ______________
Angry: ___________________
How he is coping with his illness?
Frightened: ________________
Members of household
Social roles