CASE PRESENTATION

IDENTIFICATION DATA OF THE PATIENT

 Name of patient:
 Age:
 Gender: 
 Marital Status: 
 IPD Number :
 Ward:
 Bed No :
 Address:
 Religion: 
 Education:
 Date of Admission:
 Date of Discharge:
 Diagnosis:
 Surgery (If any):
 Occupation:

 Chief Complaints with duration:

 History of present illness: 

 History of past illness:

 Past medical history:

 Past surgical history:

 Family history:
 Type:
 No. of family members:
 Any Illness:

 Family Composition:
Sl Name of the Family Age Relation Education Occupation Health
No Members With Status
. Patient
1.

2.

3.

4.

5.

 Family tree:

 History of any Illness:

 Socio-Economic Status:
 Family income :
 Enviornmental hygiene:
 Type of house:
 Personal History:
 Personal hygiene:
 Oral hygiene:
 Bath per day:
 Diet: 
 No. of meals per day:
  Food preference:
 Tea/Coffee:
 Sleep & rest :

 Elimination Pattern:
 Bowel :
 Frequency:
 Urine frequency
 During day:
 During Night:

 Habits:
 Alcohol:
 Smoking:
 Tobacco:
 Exercises :

PHYSICAL EXAMINATION
 General Appearance:
 Level of Consciousness :
 Speech :
 Height :
 Weight :
 Body Built :
 Personal Hygiene :
 Vital Signs:

Date Time Pulse Respiration BP Temperature

 Head:
 Size:
 Hair Colour:
 Scalp:
 Face:
 Facial Symmetry:
Ears:
 External Ear :
 Tympanic Membrane :
 Hearing activity :
 Webber test :

 Nose:
 External Nose :
 Nostrils :
 Sinusitis ;
 Sense of smell :
 Eyes:
 Eyes Brows :
 Eye Lashes :
 Eye Lids :
 Eye Balls :
 Conjunctiva :
 Sclera :
 Pupils :
 Vision :
 Mouth and Pharynx:
 Lips :
 Odour :
 Teeth :
 Denture :
 Buccal mucosa :
 Tongue :
 Tonsils :
 Neck:
 Lymph Nodes :
 Thyroid Gland :
  Range of Motion :
 Cardio-Respiratory System:
 Chest expansion :
 Shape :
 Any deformities :
 Breathing sound :
 Respiratory pattern :
 Respiratory rate :
 Heart :
 Heart sound :
 Murmur sound :
 Diaphragmatic excursion :
 Varicose vein :
 Abdomen:
 Inspection :
 Colour of skin :
 Presence of scar :
 Assess for lesions :
 Palpation :

 Percussion :
 Ascites :
 Auscultation :

 Bowel sound :
 Genito-urinary system:
 Urinary frequency :
 Burning micturation :
 Hematuria :
 Urethral discharge :
 Bladder tenderness :
 Musculo-skeletal system:
 Gait :
 Posture :
 Range of motion :
 Spine :
 Weakness :
 Integumentary system:
 Skin colour :
 Skin texture :
 Skin integrity :
  Lesions :
 Cyanosis :
 Edema :
 Clubbing of nail :

 Neurological Test:
 Co-Ordination Test:

 Equilibrium Test:

DISEASE DESCRIPTION
DEFINITION:

Etiology:
 According to book According to patient

 Risk Factors:

Book Picture Patient Picture

 Pathophysiology:
 Clinical Manifestations:
 Book Picture Patient Picture

Diagnostic Evaluation:

Book Picture Patient Picture

Date Investigations Patient’s Normal Value
 value

 Management:

Book Picture Patient Picture

DATE Name of the drug Dosage Route Time
Nursing Care Plan

Date Problems Needs/Goal Nursing diagnosis according

to priority basis
Date Problems Needs/Goals Nursing diagnosis according
to priority basis
Date Nursing Assessment Nursing Goal Planning Intervention Rationale Evaluation
Diagnosis
Time
Subjective data: 1

Objective data:
Date Nursing Nursing Goal Planning Intervention Rationa Evaluation
Assessment Diagnosis le
Time

Date Nursing Nursing Goal Planning Intervention Rationa Evaluation

Assessment Diagnosis le
Time
Date Nursing Nursing Goal Planning Intervention Rationa Evaluation
Assessment Diagnosis le
Time
Date Nursing Nursing Goal Planning Intervention Rationa Evaluation
Assessment Diagnosis le
Time
Date Nursing Nursing Goal Planning Intervention Rationa Evaluation
Assessment Diagnosis le
Time
 Health Education:

 Conclusion:
  Bibliography:

1:

2:

3:

4:

5: