Case study format

Name of patient:__________________________________________________________

Hospital No:______________________________________________________________

Date of hospitalization:_____________________________________________________

Duration of hospitalization:__________________________________________________

Patient Demographic Data (1 Mark)

Age:____________________________________________________________________

Address:_________________________________________________________________

Occupation:______________________________________________________________

Level of education:_________________________________________________________

Nationality:________________________Religion_________________________________

Marital status:_____________________________________________________________

Medical Data

Diagnosis:_______________________________________________________________

_______________________________________________________________________

Preoperative patient:______________________________________________________

Postoperative patient:_____________________________________________________

Name of operation:_______________________________________________________

Postoperative duration:___________________________________________________

Health History (1 Mark)

Chief complaints:___________________________________________________________

_________________________________________________________________________

Duration:_________________________________________________________________

History of present illness:____________________________________________________

_________________________________________________________________________

_________________________________________________________________________

__________________________________________________________________________
References (According to APA Format)

 If it is a book it is listed in this way: author, year, Title, Edition, Place, publisher, Chapter &
page number.

Evans, C, and Tippins , E, 2008, foundations of nursing ,1st edition, published by McGraw –
Hill Education, Chapter 15 First Aid Knowledge and Skills ,PP: 315-316.

 If it is a journal then it is listed in this way :Author ,Year, Article Title, Journal name, Edition
,Version , & page number.

Mohanan, K, Kaur, S, Das, K ,and Bhalla ,A ,2010, patient satisfaction regarding nursing
care at Emergency out patient department in a tertiary care Hospital,
Journal Of Mental Health & Human Behavior, vol. 15 No. (1), PP:54-58.

1.

2.

3.

Name of student:___________________________________________________________
Student No:____________________________ Group______________________________
Class:_____________________________________________________________________
Date of Submission:_____________________ Date:_______________________________

Signature of student:________________________________________________________

Teacher’s Evaluation Report

Total mark: 50

Total Marks Obtained:________________________________________________________

Signature of the Teacher:______________________________________________________

Date:______________________________________________________________________
Past Medical History (2 Marks)

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Definition of the Disease (1 Mark)

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Alteration/s in the Affected System (Pathophysiology) (5 Marks)

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________
 Etiology of Disease (5 Marks)

Serial According to the literature/Books In your patient

No.

Clinical Manifestation of the Disease (5 Marks)

Serial According to the literature/Books In your patient

No.
 Investigations Conducted for Your Patient (2.5 Marks)

Name of Date Results Normal range Significance of the results

investigation

Treatment Carried Out for your Patient (2.5 Marks)

A. Medical

1. pharmacological

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

2. Non pharmacological

__________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

B. Surgical

___________________________________________________________________________

___________________________________________________________________________
 Medical Treatment (5 Marks)

Name of Classification Dose Route frequency Action Possible Nursing

Drug (0.5 M) (0.5 M) (1.5 M) side responsibilities
effect (1.5 M)
(1 M)
Name of Classification Dose Route frequency Action Possible Nursing
Drug (0.5 M) (0.5 M) (1.5 M) side responsibilities
effect (1.5 M)
(1 M)
 Nursing care plan (15 Marks)

Include at least one actual and potential nursing diagnosis

Nursing diagnosis Goals (2 Marks) Nursing orders/ Rationale Outcome criteria

(3 Marks) Interventions (3 Marks) (2 Marks)
(5 Marks)
Nursing diagnosis Goals (2 Marks) Nursing orders/ Rationale Outcome criteria
(3 Marks) Interventions (3 Marks) (2 Marks)
(5 Marks)
Discharge Plan (5 Marks)

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