CASE STUDY FORMAT (MEDICAL SURGICAL)

Student's Name :Kamini

Course and Year of study :M.Sc nursing 1st year

HISTORY COLLECTION:

I. Biodata:
 Name: Mr Vikram singh
 Age: 55 years
 Gender: male
 Marital Status: married
 Religion: hindu
 Occupation: teacher
 Income: 30000/month
 Address: noida sector 18 up
 Bed number: 30
 Ward number: medical ward
 Date of Admission: 26/04/2021
 Diagnosis/ Provisional Diagnosis: pharyngitis
 Name of the consultant: Dr. Manjeet singh

II. Chief Complaints/ Presenting Complaints:

Patient is having irritation or fullness in throat, difficulty in swallowing, fever and
sore throat.

III. History of Illness:

 History of present illness: Patient come with complaints of irritation or
fullness in throat, difficulty in swallowing, fever, and sore throat.
 History of past illness: no past history of illness.

IV. Family History:

Relation
Sl Name of the family Health
Age Sex Education with
no members status
patient
1 Mr. Vikram singh 50 yrs M B.ed Patient Unhealthy
2 Mrs. Kavita 44 yrs F B.a Wife Healthy
3 Mr. Naveen 27 yrs M B.tech Son Healthy
4 Miss Neeshu 22 yrs F B.com Daughter Healthy

 Family tree.
  IV. Socio-economic Status:
 Monthly income and its sources.
 Assets
 Own house [√ ]
 Four wheelers [x ]
 Two wheelers [√ ]
 TV [√ ]
 Refrigerator [√ ]

V. Environmental Status:
 Type of house: Pucca
 Lighting and ventilation of house: Good
 Water source and it's sanitation: Good
 Drainage system: Open
 Presence of vectors such as flies, mosquitoes etc. Yes
 Waste disposal system including toilet facility: Good

VI. Personal History:

He has white complexion slim. He consume meals three times a day. He does not have habit of
smoking but drinks alcohol ocassionaly. His main hobby is reading books and news paper. He has normal
bowel pattern and sleep for about 6-7 hours with normal sleep awake schedule.

 Personal appearance and physique

Nourishment well nourished
Body built moderate
Health healthy
Activity dull

 Mental status
Consciousness conscious
Look anxious

 Posture
Body curve normal
Movement no limp
 Anthropometric measures
Height 160cm
Weight 64 kg

VII. Menstrual and Obstetric history (Women):

 Age of Menarche:
 Regular/irregular cycle
 Scanty/heavy cycle
 Last menstrual period (LMP)
 Number of pregnancies, deliveries, abortions, obstetrical surgeries

PHYSICAL ASSESSMENT:
I. General Conditions:
 Appearance : Good
 Sensorium : Good
 Co-operativeness : Good
 Gait and posture : Good
 Height and weight : normal

II. Vital Signs:

SL
VITALS PATIENT VALUE NORMAL VALUE REMARK
NO
1 Temperature 100.2 F 98.6F
2 Pulse 76 beats/min 72beats/min
3 Respiration 20/min 20/min
4 Blood Pressure 120/80mmHg 120/80mmHg
III. HEAD TO TOE ASSESSMENT:

 Head:
 Shape: normocephalic
 Scalp: clean
 Skull: normal

 Skin
 Colour pallor
 Turgor normal
 Moisture smooth
 Temperature: warm
 Lesion : free from lesion
 Scar: not present
 Nail: no colour change
 Scalp: dandruff present

 Eyes:
 Position : normal
 Eye ball : sunken
 Eye brows: well distributed
 Eye lashes: not infected
 Conjunctive : pale
 Sclera: white
 Pupils : reaction to light is normal
 Lens: opaque

 Ears:
 External ear: no discharge
 Hearing aquity: normal hearing

 Nose and Sinuses:

External nose: symmetric, no discharge
 Nasal septum: midline
Patency of nasal: air mones freely as the client
Smell : normal
 Mouth and Pharynx:
 Lips: normal
 Teeth: nomal
 Tongue: normal
 Palate: normal colour
 Tonsils: not enlargeg
 Sense of Gustation (taste): normal

 Neck:
 Range of motion: possible
 Thyroid gland: not enlarged
 Trachea : midline
 Lymph nodes: not palpable
 Jugular vein: not distended

 TRUNK: CHEST, ABDOMEN AND BACK

 Axillae:
 Inspection :symmetric, smooth, no lesion
 Palpation: no lymph axilla

Chest
 Inspection : symmetrical
 Palpation : no tenderness, no lesion
 Percussion : resonance normal
 Auscultation : there is no abnormal sound
 Heart : no murmurs

Abdomen.
 Inspection
 Shape: normal
 Pigmentation and color: normal colour
 Scars : absent
 Masses: absent

 Palpation : no tenderness, no lesion

 Auscultation
 There is no abnormal sound

EXTREMITIES: UPPER AND LOWER EXTREMITIES

 Skin
  Colour : brown
 Texture :normal
 Temperature : normal
 Lesion : absent

 UPPER EXTREMITIES
 Symmetry : symmetrical
 Range of motion: possible
 Peripheral pulse: normal rate
 Reflexes : normal
 Oedema : absent
 Cyanosis : absent
 Joints : normal
 Subjective symptoms : swallowing difficulty

 LOWER EXTREMITIES
 Symmetry : symmetrical
 Toe nails: capillary refill
 Range of motion : possible
 Oedema : absent
 Cyanosis : absent
 Subjective symptoms : weakness

V. Investigations

SL PATIENT NORMAL
DATE INVESTIGATION REMARK
NO VALUE VALUE

1 26/04/2021 Hb 13.45mg/dl 13-18gm/dl Normal

2 26/04/2021 TLC 10000cumm 4000-10000 Normal

3 26/04/2021 Neutrophils 62% 60-70% Normal

4 26/04/2021 Eosinophils 2% 1-4% Normal

5 26/04/2021 Lymphocytes 27% 20-30% Normal

6 26/04/2021 ESR 23mm 6-10mm Elevated

VI. Treatment:

SL NAME OF THE SIDE

DOSE ROUTE FREQUENY ACTION
NO DRUG EFFECT
Headache,
Anti nausea,
500mg
1 Tab: Oral inflammato vomiting,
Acetamenophen Bd ry drug lethargy,
constipation
Od Loss of
appetite
Tab Seizures
2 20 mg Oral antiviral
amanatidine Allergic
reaction

Bd Lethargy
Fatigue
Dizziness
Tab Drowsiness
3 50 mg Oral Analgesic
Voveron Loss of
appetite
Allergic
reaction

VII. Description of disease and Comparison with Client picture.

 Definition:
Pharyngitis is inflammation of the back of the throat, known as
the pharynx. It typically results in a sore throat and fever
 Related Anatomy and Physiology
The back of throat is also referred to as the pharynx. More specifically, the
pharynx is the back, upper part of the throat behind the tongue. It starts at the base
of the tongue and ends at the larynx.

Anatomy examples:
 Normal pharynx in an adult 
 Normal pharynx in a child 
 Normal tongue 

The tonsils are collections of lymphoid tissue in the back of the throat. They
are located on both sides of the throat, near the base of the tongue. The
tonsils generally shrink over time. At puberty, the tonsils are normally about
the size of an almond.
Epidemiology related to Client E

Risk factors and Etiology

RELATED TO CLIENT BOOK REVIEW INTERPRETATIONS

Adenovirus Adenovirus – Absent

influenza influenza Absent
Streptococcus pneumoniae, Streptococcus pneumoniae, Absent
Corynebacterium diphtheriae  Corynebacterium diphtheriae  Present

Pathophysiology

CHANGES IN CLIENT BOOK REVIEW INTERPRETATIONS

Fever (1 point) Fever (1 point)

Persent

Anterior cervical Anteriorcervical

Present
lymphadenopathy (1 point) lymphadenopathy (1 point)
Tonsillar exudate (1 point) Tonsillar exudate (1 point)
Present
Absence of cough (1 point) Absence of cough (1 point)
Present

Clinical features

IN CLIENT BOOK REVIEW INTERPRETATIONS

Runny nose Runny nose Present

Cough Cough Present
Headache Headache Present
A hoarse voice A hoarse voice Present

Diagnostic Evaluations with interpretation

RELATED TO CLIENT BOOK REVIEW INTERPRETATIONS

 throat culture  throat culture Present

rapid antigen detection
rapid antigen detection testing Absent
testing
Blood tests Blood tests Present

Complications:

RELATED TO CLIENT BOOK REVIEW INTERPRETATIONS

Peritonsillar abscess, , Peritonsillar abscess, , Absent

Cervical lymphadenitis Cervical lymphadenitis Absent

 Mastoiditis  Mastoiditis Absent

Management:

RELATED TO CLIENT BOOK REVIEW INTERPRETATIONS

1. MEDICAL Pain medication (Nsaid) Present

 Steroids (Dexamethasone)
 Lidocaine
Antibiotics
Oral analgesic solutions
2. SURGICAL Tonsillectomy Absent
3. NURSING  Prepare to administer Present
prescribed antibiotics,
analgesics, antitussives
and decongestants.
 Encourage the client to
gargle with warm saline
gargles and use throat
lozenges.
 Instruct the client that
the temperature of saline
should be sufficiently
high to be effective and
should be as hot as the
client can tolerate.
 Instruct the client to
apply an ice collar to
severe sore throats.
 Instruct the client on
proper mouth care.
 Instruct the client to
have a liquid or soft
diet.
 Encourage the client to
increase fluid intake to
2,000 ml/per day
 Discourage the client
from eating spicy foods
and drinking juices that
are acidic.
 If the client is unable to
drink, fluids may be
administered IV.
 Instruct the client to take
all antibiotics, even if he
 is feeling better

1. Nursing Care Plan:

SL NURSING IMPLEMENT
ASSESSMENT GOALS EVALUATION REMARK
NO DIAGNOSIS ATION

2. Health Education:
For easing the pain of a sore throat -
Suck on a throat lozenge, hard candy or papsicle; take acetaminophen or
ibuprofen, gargle with warm salt water (1/4 tsp. salt per glass of water ); drink
plenty of liquids; and eat soft, bland foods. Throat sprays can also provide pain
relief.

Bibliography