Comprehensive Case Study Format

1. Personal information: (2 Marks)

Patient initials:
Age: Address: Hospital NO:
Date of Admission/ OPD Visit: Date of Discharge:

2. Family History: (1 Mark)

3. Medical and Surgical History: (2 Marks)

4. Obstetrical History (Fill for ANC/PNC cases. If newborn case fills for the
newborn’s mother): (2 Marks)

 Gravida: Para: Abortion: Fetal death

 Died: Alive:

 L.M.P EDD (Scan): EDD (history):

5. Medical Diagnosis: (2 Marks)

(Example: G4, P3, L3, A0, 38weeks with PIH)

6. Chief Complaint: (Admission and present complain with duration) (2 Marks)

7. Definition of final diagnosis: (3 Marks)

(Example: A mother is G4, P3, L3, A0, 39 weeks with PIH, Oligohydramnios,
delivered by LSCS. In this case define PIH, Oligohydramnios and LSCS)
 8. Etiology of the disease: (4 Marks)
(Example: A mother is G4, P3, L3, A0, 39 weeks with PIH, Oligohydramnios,
delivered by LSCS. In this case write the etiology for PIH, Oligohydramnios and
LSCS)

SI.
NO
According to text book In your patient

9. Clinical manifestations: (4 Marks)

(Example: A mother is G4, P3, L3, A0, 39 weeks with PIH, Oligohydramnios,
delivered by LSCS. In this case write the clinical manifestations for PIH,
Oligohydramnios and LSCS)
SI. According to text book In your patient
NO

10. Management: (4 Marks)

(Example: A mother is G4, P3, L3, A0, 39 weeks with PIH, Oligohydramnios,
delivered by LSCS. In this case write the management for PIH, Oligohydramnios and
pre or post LSCS)

SI. According to text book In your patient

NO

11. Pathophysiology of the disease: (4 Marks)

(If no Pathophysiology, focus on the effect of disease on woman & fetus)
(Example: A mother is G4, P3, L3, A0, 39 weeks with PIH, Oligohydramnios,
delivered by LSCS. In this case correlate the diseases and their process to each other,
correlate PIH with Oligohydramnios with LSCS)

12. Investigation: (8 Marks)

(In case of antenatal case study, include booking and resent investigations)
Investigation Result Normal findings Interpretation
13. Physical assessment (Head to toe): (5 Marks)

Area Findings Interpretations

15. Focused physical examination: (5 Marks)

(Include abdominal examination for ANC case, BUBBLE for postnatal case,
Head to toe assessment for newborn and gynecological case)

15. Medications: (8 Marks)

Drug Dose Route Frequency Classifications Action Side Nursing

Name Effect Responsibility

16. List of all nursing diagnosis with prioritization use PES format: (4 Marks)
Note: Include appropriate nursing diagnosis for the mother and newborn in case of
postnatal case study.

17. Nursing care plan: (20 Marks)

Assessment Diagnosis Goals Interventions Rationale Evaluation

18. Health education plan: (4 Marks)

Include health teaching points under heading which is appropriate for all the needs of
the mother and newborn with rational.

19. Evidence: (8 Marks)

Provide best evidence from the literature to support nursing care plan, health
education, treatment or investigations. (Use recent publication not more than 5
years). The evidence should be analyzed:

- How it is related to your patient

- Summary of literature finding (PICO)
- Compare literature finding with real practice
- Implication in practice
20. Reflection: (Use Gibbs reflective cycle) (3 Marks)

21. References: (3 Marks)

(Use Harvard or APA format for referencing)

22. Organization of case study: (2 Marks)

Follow the general guidelines of case study.

Marks obtained = X 35
100

Teacher’s Signature:
Date: