FORMAT OF THE CLINICAL CASE STUDY

 COVER PAGE CONTAINING

 Title of the case study
 Name of the student
 Venue
 Name of supervisor/facilitator
 Date of submission

 :PERSONAL PARTICULARS/SOCIO-DEMOGRAPHIC INFORMATION
Personal data including name, address, date of birth, gender, religion, race/ethnic origin,
occupation, and type of health plan/insurance should be included. This information may
be useful in helping to foster understanding of a client’s perspective.

CHIEF COMPLAINT/ CLIENT MAIN COMPLAINT (REASON FOR SEEKING

HEALTH CARE) the client’s reason for seeking health care should be described in the
client’s own words. pervaginal bleeding and fetal movement . signs of labour like
contraction, leaking liquor or passing show. Her blood pressure and complain of
headache, blurred vission or fits, Lethargy or pallor. Identify the chief complain

ANTENATAL HISTORY :
Urinary pregnancy test and the initial booking. Dating scan was done,Antenatal screening

Blood pressure ,Urine ,Hemoglobin ,Weight ,Height ,Blood Group ,VDRL/HIV/Hep B

MGTT(modified glucose tolerance test)

 PAST OBSTETRIC HISTORY: GPL, weight sex score, abortion, miscarriege, iufd

 PAST GYNAECOLOGICAL HISTORY: menstrual cycle, history of dysmenorrhea,

menorrhagia, or intermenstrual bleeding.. contraception,

.
 PAST MEDICAL/ SURGICAL HISTORY
The history and timing of any previous experiences with illness, surgery, or
hospitalization are helpful in order to assess recurrent conditions and to anticipate
responses to illness, since prior experiences often have an impact on current responses.

FAMILY MEDICAL HISTORY/ FAMILY HISTORY

The nurse needs to determine any family history of acute and chronic illnesses that tend
to be familiar. Health history forms will frequently include checklists of various illnesses
that the nurse can use as the basis of the questions about this aspect. The client should be
instructed that family history refers to blood relatives. It is also helpful to indicate who
the relative is in relation to the client (e.g., mother, father, sister).

ALLERGIES/ NUTITIONAL HISTORY

Description of Prior allergic reactions to medications, food, or environmental substances

REVIEW OF OTHER SYSTEMS (ROS)

The review of systems (ROS) is a brief account from the client of any recent signs or
symptoms associated with any of the body systems. This allows the client an opportunity
to communicate any deviations from normal that have not been otherwise identified. The
review of systems relies on subjective information provided by the client rather than on
the nurse’s own physical examination.

Relevant clinical examination

General examination [quick assessment]

How she looks, comfortably. Communicative and alert.

Her vital signs are as follows:

Blood pressure:
Pulse rate

Temperature

On peripheral examination clubbing noted at both of her hands. pallor and the capillary
refill ,palmar , Both of her eyes conjunctiva [pink or yellow] discolouration of sclera.

Systemic examination

ABDOMINAL EXAMINATION;Upon inspection of the abdomen. The abdomen shape. linea

nigra and stria gravidarum. The umbilical .On palpation the uterus how is look like, irritable and
the abdomen is soft or tender. The symphysio fundal height,auscultation

CARDIOVASCULAR SYSTEM EXAMINATION; Radial pulse and rhythm. Upon

auscultation there is dual rhythm and no murmur heard.

RESPIRATORY EXAMINATION; Chest expansion [bilaterally or not], breath sound heard .

THYROID EXAMINATION ;throid swelling either and cervical lymph nodes palpable.

BREAST EXAMINATION;Mass noted, shape of nipple , axillary lymph node

PER VAGINAL EXAMINATION; Pv result identifying all pv examination

RECENT DIAGNOSIS/PROBLEM IDENTIFIED [ here is the

case study ] talk more about your case. Give detail of the current issue ,
explain what happen

Identifying current diagnosis of the patient [Identify the problems in terms of priority]. Give
detail of the diagnosis
RELEVANT INVESTIGATION DONE with reasons and the result

IMMEDIATE AND SUBSEQUENT MANAGEMENT [tell about drug dose, fluid how many
liter, non pharmacological aproach

THE PROGNOSIS (EVALUATION AND OUTCOMES). Tell about the outcome after ther
procedure both mother and infant/newborn

NURSING CARE PLAN CONTAINING THE FOLLOWING PARTS.

  Nursing Diagnoses
 Goals/ Expected outcome
 Intervention/Implementation
 Evaluation

DISEASE PROFILE WITH THE FOLLOWING PARTS go direct to your case, be

specific search material based on the case don’t copy facilitator guide
 Definition/ Meaning
 Risk/predisposing factors (if any)
 Causes
 Types
 Diagnostic measures
 Management/ Treatment
 Preventive measurers

REFERENCES