CASE STUDY

DEMOGRAPHIC DATA

Name: ________________________________
Age: ________________________________
Gender: ________________________________
Address: _________________________________________________________
Education: ________________________________
Occupation:________________________________
Marital status:____________________________
Religion:__________________________________

BRIEF SOCIOECONOMIC HISTORY

Health status of family members:

_________________________________________

Total income:
_________________________________________

Dietary habits:
_________________________________________

Housing condition:
_________________________________________

Interpersonal relationship:
_________________________________________

PERSONAL HISTORY

Personal hygiene
____________________________________

History of allergy:
____________________________________

History of past illness:

____________________________________

History of present illness:

____________________________________
VITAL SIGNS
BP
TEMP
CR
RR
SpO2
PAIN

HEIGHT:
WEIGHT:

General appearance:

Blood type:
Posture:
Gait:
Activity of Daily Living:

DOCUMENTATION OF ASSESSMENT FINDINGS ON A NARRATIVE PROGRESS NOTE

FOR SUBJECTIVE DATA
COLDSDPA CLIENT’s RESPONSE FOR __CHIEF COMPLAINT__
CHARACTER
ONSET
LOCATION
DURATION
SEVERITY
PATTERN (what
makes it better
or worst)
ASSOCIATED
FACTORS
THE REVIEW OF THE SYSTEM FOR ____Name_______
SKIN,
HAIR AND
NAILS

HEAD POSITION:

NECK NECK MUSCLES:

LYMPH NODES:
THYROID GLAND:
TRACHEA:

EYES POSITION AND ALIGNMENT:

EYEBROWS:
EYELIDS:
LACRIMAL DUCTS:
CONJUNCTIVA:
SCLERA:
CORNEA:
PUPILS:
LENS:
VISUAL ACUITY:

EARS AURICLES:
EAR DRUM:
HEARING ACUITY:
MOUTH, THROAT, NOSE LIPS:
AND SINUSES MUCOSA:
GUMS:
TEETH:
TONGUE:
PALATE:
PHARYNX:

THORAX AND LUNGS POSTERIOR

CONTOUR:
INTERCOSTAL SPACES:
RHYTHM OF BREATHING:
THORACIC MUSCLES:
FREMITUS:
PERCUSSION:
AUSCULTATION:

ANTERIOR THORAX
THORACIC MUSCLES:
FREMITUS:
PERCUSSION:
AUSCULTATION:

LATERAL THORAX:
PERCUSSION:
BREAST AND REGIONAL LEFT BREAST:
LYMPHATICS RIGHT BREAST:
NIPPLE:
OUTER PART:

HEART AND NECK VESSELS HEART SOUND:

PERIPHERAL VASCULAR TEMPERATURE:

CAPILLARY REFILL:
DISTAL/PROXIMAL PULSES:
SENSATION IN LIMBS:

ABDOMEN 9 QUADRANTS

MUSCULOSKELETAL INSPECTION:
PALPATION:
RANGE OF MOTION:
MUSCLE TONE AND STRENGHT:

NEUROLOGIC GCS: E- V- M-
CRANIAL NERVES I-XII (*just note
abnormalities)

FEMALE/MALE GENITALIA FEMALE

LABIA MAJORA:
LABIA MINORA:
URETHRAL ORIFICE:
VAGINAL ORIFICE:

MALE
PENIS:
SCROTUM:
INGUINAL RING AND CANAL:

ANUS AND RECTUM AND/OR INSPECTION:

PROSTATE DIGITAL PALPATION:

24 HOURS DIETARY RECALL:

MAINTENANCE MEDICATIONS:

LIFESTYLE AND HEALTH PRACTICES PROFILE:

PREPARED BY:

________________________, SN
BSN 2 -YA- BLOCK 3
SEPTEMBER , 2023

PROFESSOR:

_______________________