A Case Study on (Topic)

In Partial Fulfillment of the Requirements

in Clinical Education 1

Submitted to:
(CI’s Name, Title)
Clinical Instructor

Submitted by:
(Student’s Name)
Group #

Date Submitted:
FONT: ARIAL 12, 1.5 spacing, JUSTIFY

I. Cover Pgae
II. Table of Contents
III. Introduction
 1 ½ page long
 Definition of rotation
 Brief definition of the disease
 Statistics of the disease (international, national, local)
 Significance/ why did the group chose the study
 Implication of the study to RT education, practice and research
IV. Objectives
A. General Objective – should be 3rd person and directed to KNOWLEDGE SKILLS AND
ATTITUDE
B. Specific Objectives- use Bloom’s Taxonomy in formatting
V. Definition of Diagnosis- at least 3 references within 5 years (NO WIKIPEDIA)
-Reference format (Author, Title)
VI. Personal Data
A. Biographical Data
B. Medical Data
VII. Patient History
A. Past Health History – anything unrelated to the present illness
B. Maternal Health History (if neonate)
C. Present Health History- from the start of the disease, include patient’s lifestyle, diet,
medications taken, laboratories, compliance and other belief for treatment such as
consultation to a quack doctor or other alternative
D. Genogram- 3 generations with a different page for Narrative. Use legend for diseases ,
deceased and gender, include the age of each family member
VIII. Assessment
A. Physical
i. General Survey- describe how the patient looks like upon entering the room ,
include the MV settings
ii. Vital Signs
iii. Head
iv. Eyes
v. Ears
vi. Nose
vii. Mouth
viii. Neck
ix. Thorax and Lungs
x. Abdomen
xi. Upper Extremities
xii. Lower Extremities

NOTE: THOROUGH ASSESSMENT, both normal and abnormal

 B. Reflex (if infant)
Reflex Present/ Not Present Rationale
C. Developmental Task (Havighurst and Erik Erikson or CI’s preference)
Task Met/ Unmet Rationale

IX. Anatomy and Physiology

 Respiratory System
 Other system directly involved with the disease process
 Can use pictures of the systems involved
X. Pathophysiology
A. Factors
Predisposing
Factor Rationale
Precipitating
Factor Rationale
B. Diagram
Legends:
 Signs and Symptoms
 Diagnostics
 Therapy
 Medications
C. Narrative
XI. Diagnostics
A. Actual
B. Other Possible Diagnostic Tests (if applicable)
XII. Drug Study
 Same format with weekly drug study
XIII. Respiratory Therapy Care Plan
S
O
A- CI’s preference
P- should have general and specific
I- DEPENDENT and INDEPENDENT, with RATIONALE
E
R – Pulmo Rehab, MV set-up suggestion, etc
XIV. Pulmonary Rehabilitation
METHOD
XV. Prognosis- relating to patient’s compliance and perception to condition, family support,
financial status, etc
XVI. Refereces
A. Books APA format, within 5 years, in ALPHABETICAL ORDER
B. Website NO WIKIPEDIA