CASE STUDY FORMAT

Introduction:

Patient's Demographic Data:

Patient Initial: ________________________ Hospital No: _____

Age______________________ Sex: ________________ Tribe: _________________

Address: _____________________________________________________________

Occupation: __________________________________________________________

Level of Education: ____________________________________________________

Nationality: __________________________ Religion: ________________________

Marital status: _________________________

Medical Diagnosis: _________________________

Date of Admission: _________________________

Duration of Hospitalization: ______________________

HEALTH HISTORY:

Present history/Chief complaints:

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Psychosocial Science Academic Year 2018-2019 Page 13 of 43
Past Medical History: (past medical & surgical history and family history of any illness,)
PSYCHOSOCIAL RESPONSES AND COPING MECHANISMS
Sl No Various Description of the
psychosocial psychosocial responses
responses exhibited identified (as in
by the patient and literature)
family
Anxiety Universal, primitive un
pleasant feeling of
tension and
apprehension
Hopelessness
It is an emotion characterized by
a lack of hope, optimism, and
passion. An individual who feels
hopeless may often have no
expectation of future
improvement or success.
Powerlessness  
Perception that one’s own action
will not significantly affect an
outcome; a perceived lack of
control over a current situation or
immediate happening.
Psychosocial Science Academic Year 2018-2019
Observations in the
patient or family from
which you identified the
psychosocial responses
He feels anxious,
restless, and angry most
of the time. His facial
expressions indicate that
he is anxious and does
not talk much. He
isolates himself from
people and does not
come into contact with
them.
The patient is very mad ,
he is afraid of treatment, he
believes that his health
condition will not improve
and that why he refused to
increase dose of the
medication.
The patient looks very
tired. He does not have
power and energy to
preform daily life activity.
Also he don’t want to talk
or communicate with others
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Sl No Various coping Description of the Observations in the
mechanisms or identified coping patient or family from
defense mechanisms mechanisms or defense which the various coping
used by the patient mechanisms (as in mechanisms or defense
and family literature ) mechanisms
identified

EVIDENCE:

Provide best evidence from the literature to support one concept you identified in your
patient. The evidence should be analyzed

1) How it is related to your patient?

2) Summary of literature finding:

1) Explain in which area of the study support or contradict your analysis of your patient
condition

Psychosocial Science Academic Year 2018-2019 Page 15 of 43

CONCLUSION:

REFERENCES: (Harvard Style)

1.

2.

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