CASE STUDY FORMAT

I.

Introduction
It is the abstract of the whole case study and this provides a brief background
of patients demographic data, past medical history, and history of present
illness. Introduction also gives a birds eye view of the patients diagnosis,
pathophysiology, prevalence/incidence rate of the disease of the patient,
medical/surgical management and lists the identified nursing problems.

II.

Patient demographic data

Demographic data included in this section are: patients age, sex, marital
status, birthday, birthplace, region, race, religion, highest educational
attainment, and occupation. These data are of importance in determining
possible precipitating and predisposing factors to certain illness or disease
process.

III.

Past Medical History

Includes previous hospitalizations, any history of surgical procedures, and
immunization history

IV.

Family History of Illness and social history

It determines the familial connections of some disease processes that the
patient might be experiencing. This seeks for the family history of some
diseases and is not limited to Diabetes, Hypertension, Cardiovascular
disease, Stroke, Cancer, Asthma, and Tuberculosis. If the patient is female,
Maternal and gynecologic history must also be obtained.
Social history includes the personal history of patient about his vices, and is
not limited to smoking, alcohol intake, and drug use.

V.

Admitting history
This explains how the patient was brought to the hospital, the presenting
signs and symptoms upon consult/arrival.

VI.

VII.

Physical examination and review of systems during admission

This is the area of the study in which physical and clinical assessment will be
detailed, the data to be written here will be coming from the admission
physical assessment and review of systems.
Physiopathology of the patients disease process

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TDMH NSO, Room 301, 3rd floor, No. 6 Rizal Ave. San Isidro, Taytay, Rizal Philippines
Tel. No. 706-7101/02 loc. 206. Cell. No. +63917-6696086. Email: tdmhnso@yahoo.com

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It discusses the anatomy and physiology of a specific system wherein the

patient is having problem with and concurrently the patients specific disease
process and showing its connection to the presenting signs and symptoms.
VIII.

Course in the ward

This details the specific medical/surgical/gynecologic management of the
patient. What medications have been given, diagnostic procedures, and
nursing management may it be independent, dependent or interdependent.

IX.

Nursing Problem List (Nursing Diagnoses)

It lists down the identified nursing diagnoses, which could be a risk diagnosis,
actual nursing diagnosis, or wellness diagnosis. At least minimum of eight (8)
nursing diagnosis must be identified in this study.

X.

Care Plan
This entails the nursing measures done and planned to be done to the patient
for the specific nursing diagnosis identified. The top three (3) identified
priority nursing diagnoses are the ones should have the care plan. This
includes patient assessment, identifying risks, actual problems, and wellness
of the patient, planning of the interventions to be done, implementation of
plan, and evaluation of the successfulness of the plan of care given.

XI.

Drug Study
Lists the drugs given to the patient during his course of hospitalization; the
drug study includes the name of the generic name of the drug, brand names
available, stocks available and specifically used for the patient, the dosage
given to the patient, route of administration, mechanism of action, indication,
contraindications, adverse effect, side effects, drug-to-drug, food-to-drug,
and drug-to-food interactions, and of course the healthcare provider
responsibilities giving this type of medication.

XII.

Laboratory / Diagnostic examinations

Shows the diagnostic examination done to the patient with result, and relates
clinically to the condition of the patient and its possible causes and effects.

Nursing Training Service

TDMH NSO, Room 301, 3rd floor, No. 6 Rizal Ave. San Isidro, Taytay, Rizal Philippines
Tel. No. 706-7101/02 loc. 206. Cell. No. +63917-6696086. Email: tdmhnso@yahoo.com

Accredited Healthcare
Provider