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University of San Carlos

College of Nursing

Cebu City

CASE STUDY FORMAT

I. PATIENT DEMOGRAPHIC PROFILE:Name: _____________________________Age/Gender:________ Status:______

Home Address: ____________________________________________________

____________________________________________________Religion: _______________Nationality:___________ Occupation: ___________

II. HEALTH HISTORY PROFILE:A. Past Medical History

1. Pediatric and Adult Illness

Date Illness Medication Remarks

2. Immunizations

Vaccine Doses Dates Remarks

3. Hospitalization

Date & Year Hospital Institution Diagnosis Duration

4. Injuries and Accidents

5. Transfusions

6. Allergies (specify)

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B. Family History (support with a genogram and limit to two (2) generations if patient

can recall)

C. Social and Personal History

1. Occupation

2. No. of Children

3. Military experience, foreign travel

4. Habits

5. Diet

6. Type of family

7. Cultural and Religious Beliefs

8. Brief description of average day

D. Review of System (for the past 6 months). Physical Assessment

General Weight loss fatigue anorexia night sweats chills

fever weakness

Skin Itch rash lesions bruising

bleeding color change

Eyes Pain discharge itch vision lossexcessive tearing diplopia glasses/contact lens

date of last exam

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Nose Obstruction discharge epistaxis

Throat & Mouth Sore throats bleeding gums toothache dentures

Neck & Head Swelling dysphagia hoarseness

Chest Cough sputum: amount & character hemophysis wheeze

pain on respiration dyspea

Cardiovascular Precordial pain palpitation dyspnea on exertion

paroxysmal nocturnal dyspnea orthopneaedema heart murmur thrombophlebitis claudication

Gastrointestinal Heartburn nausea vomiting bloating diarrhea foodintolerance excessive gas constipation change in bowel

movement jaundice melena hemmorhoids hernia

Genitourinary Oliguria polyguria hematuria dysuria anuria

change of bladders/bowel movement

Extremities Joint pains varicose veins claudication backpain

edema stiffness deformities

Endocrine Hot flashes hairloss temperature intolerance

polydipsia goiter

Neurology Numbness tingling tremor fainting headaches mucle

Weakness ataxia unconsciousness paralysis/paresis memory

loss

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Psych Anxiety depression sexual problems insomnia

nightmares

Others

III. CURRENT HEALTH PROFILE:

A. Presenting complaints and medical diagnosis to include interventions done

prior to hospitalization.

B. Application of Nursing Process.

1. Assessment Findings (head-to-toe)

Laboratory/diagnostic Results

Date Lab. Exam Patient results Normal

findings

Interpretation/significant

findings