CASE STUDY FORMAT I.

PATIENT DEMOGRAPHIC PROFILE: NAME: ____________________ AGE/GENDER: ________ STATUS: _______ HOME ADDRESS: _________________________________________________ RELIGION: _________________ NATIONALITY: ______________________ OCCUPATION: _____________ HEALTH HISTORY PROFILE: A. Past Medical History 1. Pediatric and Adult Illness DATE ILLNESS MEDICATION REMARKS

II.

2. Immunization IMMUNIZATIONS DOSES DATE REMARKS

3. Hospitalization DATE & YEAR HOSPITAL INSTITUTION DIAGNOSIS DURATION (NO. OF DAYS)

4. Injuries and Accidents: _______________________________________ 5. Transfusions: _______________________________________________ 6. Allergies: ___________________________________________________ B. FAMILY HISTORY

C.

SOCIAL AND PERSONAL HISTORY OCCUPATION: NUMBER OF CHILDREN: ____________________________________ ___________________________________________________________ MILITARY EXPERIENCE; FOREIGN TRAVEL: _________________ ___________________________________________________________ HABITS (tobacco, alcohol, non-prescription drug, others): ___________ ___________________________________________________________ Diet: ______________________________________________________ ___________________________________________________________ TYPE OF FAMILY: __________________________________________ ___________________________________________________________ CULTURAL AND RELIGIOUS BELIEFS: _______________________ ___________________________________________________________ BRIEF DESCRIPTION OF AVERAGE DAY

REVIEW OF SYSTEM (for the past 6 months) Physical Assessment General Skin Eyes Ears Nose Throat and mouth Neck and Head Chest Cardiovascular Weight loss Weakness Itch Pain Rash Fatigue Lesions Anorexia Bleeding Night Sweats Color Changes Diplopia Chills Fever

Bruising Excessive tearing

Discharges

Itch

Vision loss

Earaches

Discharges Tinnitus Discharges

Hearing loss

Obstruction Sore throat Swelling

Epistaxis Toothaches Dentures

Bleeding gums dysphagia

Hoarseness

Cough Sputum:Amount & Character Hemoptysis Wheeze Dyspnea Pain on respiration Precordial pain Palpitation Paroxysmal Nocturnal Dyspnea Heart murmur Thrombophlebitis Dyspnea on excretion Orthopnea Edema Claudication

Gastrointestinal Heartburn Nausea Vomiting Bloating Diarrhea Food Intolerance Hernia Constipation Melena Hemorrhoids Jaundice Excessive gas or indication Genitourinary Extremities Endocrine Urinary Tract Infection Joint pains Varicose veins Deformities Stiffness Caludication Edema Back pain

Hot Flashes Hair loss Polydipsia Goiter Temperature Intolerance

Neurology Psych Others

Numbness Fainting Headaches Tremor Dizziness Seizures Memory loss Muscle weakness Alaxia Tingling Paralysis/Paresis Anxiety Depression Sexual Problems Insomnia Nightmares

CURRENT HEALTH PROFILE A. Presenting complaints and medical diagnosis to include intervention done prior to hospitalization. _________________________________________________________________ _ _________________________________________________________________ _ B. Application of the Nursing Process General Skin Eyes Ears Nose Throat and mouth Neck and Head Chest Cardiovascular Gastrointestinal Genitourinary Extremities Endocrine

Neurology Psych Others

Date

C. Laboratory/Diagnostic Results Lab Exams Patients Normal Results Findings

Interpretation/Significance