CASE PRESENTATION

1. IDENTIFICATION DATA
 Name of the Patient:
 Father/Husband’s Name:
 Age:
 Sex:
 Religion:
 Marital Status:
 Educational Status:
 Occupation:
 Monthly Income:
 Date of Admission:
 IP No.:
 Bed No.:
 Diagnosis:

 Doctor’s Name:
 Date of Surgery:
 Post-Operative day(P.O.D):
2. CHIEF COMPLAINTS:

3. MEDICAL HISTORY
 Past medical history:

 Present medical history:

4. SURGICAL HISTORY
 Past surgical history:

 Present surgical history:

 5. FAMILY HISTORY
 Family Tree:

 Family information:
S. Name of the Relationship Age Education Occupatio Marital Health
No. family with the n Status Education
member Patient

6. PERSONAL HISTORY
 Menstrual history:
 Habits:
 Likes/Dislikes:
 Diet:
 Rest/Sleep:
 Elimination pattern:

7. SOCIO ECONOMIC STATUS

8. PHYSICAL ASSESSMENT
General appearance:
 Level of Consciousness: Conscious/Unconscious/Semiconscious/Coma
 Orientation: To Place/Person/Time
 Activity: Active/Dull/Lethargy
 Body Built: Mild/Moderate/Thin/Obese
 Height
 Weight

Vital signs:
 Temperature:
 Pulse:
 Respiration:
 Blood Pressure:

Head:
 Hair: Equally Distributed/Baldhead
 Colour of the Hair: Gray/White/Black
 Pediculosis: Present/Absent

Face:
 Face: Symmetrical/Asymmetrical
 Facial Puffiness: Present/Absent

Eyes:
 Eye Brows: Symmetrical/Asymmetrical/Scaling/Lesions
 Eyelid/Lashes: Redness/Swelling/Discharge/Lesions
 Eye Ball: Sunken/Protrusion/Normal
 Conjunctiva: Colour/Swelling/Lesions
 Sclera: White/Pink/Yellow/Tenderness/Discharge/Lesions
 Cornea: Regular/Irregular Ridges
 Iris: Flat/Irregular Shape Eyes
 Eye Discharge: Present/Absent
 Use of Glasses: Yes/No
 Pupils
 Equally Reacting to Light:
 Size:
 Dilated and Fixed, Unequal:
 Visual Acuity
 Nose
 Nasal Septum: Deviated/Central
 Nasal Polyps: Present/Absent
 Nasal Discharge: Present/Absent

Mouth
 Number of Teeth:
 Dentures: Present/Absent
 Dental Caries: Present/Absent
 Odour of Mouth: Foul Smell/Acetone Smell/Others
 Gums: Weak/Swollen/Pale Colour/Healthy

Lips
 Cracked/Healthy
 Cleft Lips: Unilateral/Bilateral
 Stomatitis: Present/Absent

Sinus
 Maxillary Sinus Infection: Yes/No
 Frontal Sinus Infection: Yes/No

Ears
 Size:
 Shape:
 Position and Alignment:
 Redness: Present/Absent
 Discharge: Present/Absent
 Cerumen: Present/Absent
 Lesions: Present/Absent
 Foreign Body: Present/Absent
 Hearing Acuity:
 Use of Hearing Aids: Yes/No
 Tuning Fork Test:
 Weber Test:
 Rinne Test:

Breast

 Male:
o Lump:
o Swelling:
 o Gynecomastia:
 Female:
o Symmetry:
o Pain:
o Lump:
o Discharge
o Trauma:
o History of Breast Disease:
o Breast Surgery:
o
9. REVIEW OF SYSTEM
Respiratory System
Inspection:
 Thoracic Cage-Shape: Barrel chest/Scoliosis/Kyphosis/Normal
 Configuration: Pectus Excavatum/Pectus Carinatum/Normal
 Skin Colour and Condition: Normal/Cyanosis/Pallor
 Chest Expansion: Symmetric/Asymmetric

Palpation:

 Pain/swelling
 Position of the apex beat and trachea
 Expansion of chest:-symmetrical/asymmetrical
 Vocal fremitus
 Tactile fremitus

Percussion:

 Lung Field: Clear

 Resonance: Hyper Resonance/Dull
 Diaphragmatic Excursion: Dull/Normal

Auscultation

 Breathing Sound: Broncho/Broncho Vesicular/Vesicular

 Adventitious Sound: Crackles/Wheeze/Ronchi
 Respiratory Pattern: Normal/Tachypnoea/Bradypnea/Cheyne
Stokes/Hypo/Hyper Ventilation

Cardio vascular system

 Pulse
 Heart Sound: S1, S2 Heard
 Abnormal Heart Sound: S3 OR S4 Present/Absent
 Murmurs: Present/Absent
  Carotid Pulse Rate:
 Blood Pressure

Peripheral Lymphatic System

 Inspection and Palpate the Leg: Cyanosis/Uni/Bilateral Edema
 Posterior Tibia Pulse: Right
 Dorsalis Pedis Pulse: Right
 Edema: Present/Absent
 Type of Edema: Pitting/Pretibial Generalize
 Lymph Edema: Present/Absent
 Varicose Veins: Present/Absent
 Venous Ulcer: Present/Absent

Digestive System
 Abdominal Girth:
 Diarrhoea/Constipation:

Inspection:

 Size: Scaphoid/Protuberant/Flat/Round
 Symmetry: Bulges/Masses/Hernia
 Scar:
 Lesions:
 Redness:

Palpation:

 Tenderness: Present/Absent
 Fluid Collection: Present/Absent
 Mass/Soft:

Percussion
• Ascitis/Peritonitis
• No Gas/Fluid Collection
Auscultation

 Bowel Sound: Normal/Borborygmic/Absent

Genitourinary System
 Frequency of urination:
 Urine last voided:
 Colour: Normal/Anuria/Haematuria/Dysuria/Incontinence/Any other
  Catheter present: Yes/No
 Urethral discharge: Yes/No

Integumentary System
 Skin Colour:
 Dermatitis:
 Allergies: Cause:
 Lesions, Abrasions:
 Tenderness, redness:
 Surgical growth:
 Abnormal growth:
 Secretion:

Musculoskeletal System
 Range of motion:
 Joint: Swelling/Pain/Other:
 Weakness/Paralysis/Contracture:
 Extremity strength: Equal/Unequal
 Spine: Lordosis/Kyphosis/Scoliosis/Normal

10. DRUG PROFILE

S. Generic Classifi Dose/ Mechanism Side- Contrain Nurse responsibility

No Name cation Route of action effect dication
and /
Trade Frequ
Name ency
 11. LABORATORY/OTHER INVESTIGATION

[Link] Date Investigation Normal finding Patient’s Finding Remarks

.

Special Findings:

DISEASE CONDITION

Introduction:

Definition:
Etiology:

Pathophysiology with Illustration:

Clinical Manifestation:
Diagnostic Evaluation:

MANAGEMENT:
Medical Management:

Surgical Management:
Complications:

THEORY APPLICATION
 NURSING CARE PLAN
List of nursing diagnosis (According to priority)
CARE PLAN

Assessment Nursing Goal Planning Rational Implementation Evaluation

Diagnosis
Subjective
data:

Objective
data:
12. HEALTH EDUCATION:

13. PROGRESS OF PATIENT:

14. CONCLUSION:
[Link]