CASE STUDY

‫جامعه الزقازيق‬
‫كليه التمريض‬

Patient Name; Hospital;

Date Of Birth; / / Ward;
Gender  Male  Female Date of Admission; / /
Biographic data

Occupation  Working  Not Working

Marital state  Single  married  widowed  divorced
 primary  secondary  university  other Information obtained from;
Education
 illiterate  others…... Nicotine use  Yes  No
Religion; No. of packs /day;
Living state  lives alone  lives with family  homeless Drug Abuse  Yes  No
Residence  Rural  Urban

Chief compliant "patient statement of reason for admission" ;

Patient knowledge about his condition  No knowledge  Partially aware  Fully aware
Medical diagnosis;
Present illness

Allergy  No  Yes Specify;

Vital Bl.p / mmHg RR C/M Weight Height

signs Temp ºc HR B/M Blood glucose;  N/A
 Severe Visual  Mild to moderate vision  Severe hearing  Mild to moderate
Vision problems problems Hearing problems hearing problems
 Use vision aids  No problems  Use hearing aids  No problems
 Chronic condition Yes No Past Surgical History; Family history Yes No
Hypertension Hypertension
History and chronic condition

Diabetes Diabetes
COPD Cancer
Asthma Past medical History; Others;
HCV
Heart disease Growth and development;
CKD Immunization of COVID-19;  Yes  No
Others; Others; Childhood diseases;

Previous hospitalization  No  Yes Reasons….

 No difficulty to fall  difficulty to fall sleep No. of sleep hours during night;
Sleep and rest sleep
Can take naps during day?  Yes  No Use drugs to sleep?  Yes  No

Weight control BMI=  Underweight  Normal  Overweight  Obese

Health pattern

 Regular  Special, enumerate…...

Diet Amount of fluid/water per day;

Salt  Low  Usual  High Sugar  Low  Usual  High
Fat  Low  Usual  High Appetite  Good  Poor  Anorexia
Activity and  Active life style  Sedentary life style  Extremely inactive
exercise
Environmental hazards
 Personal hygiene  Dependent  Partially dependent  Independent
Functional assessment

Toileting  Dependent  Partially dependent  Independent

Eating  Dependent  Partially dependent  Independent
Ambulatory  Dependent  Partially dependent  Independent
 Yes  No if yes  Walker  Wheel chair  Cane
Use assistive devices
 Stretcher  Crutcher  Others

Lab Investigation
ITEM RESULT Normal range
Radiology investigation
 Physical assessment (mark abnormal/problem findings)
 Fever  Constipation  Diarrhea  Anorexia
 Fatigue
 Dysphagia  Abdominal pain  Melena
 Sleep problems ( )

GIT
General

 Loss of appetite  Hematemesis  Nausea  Vomiting

 Anxiety  Oral infection  Jaundice 
 Fatigue
 Activity intolerance
 Others;
 Weight changes  Loss  Gain Ear Nose Mouth & Throat
 Warm  Cool  Dry  Moist  Infection  Congestion  Teeth problems
Condition Site  Pain  Frequent colds  Tonsilitis
 Bruises  Hearing problems  Bleeding  Hoarseness
 Lacerations  Vertigo  Sinusitis  Sore throat

ENT
 Rashes  Tinnitus  Others;  Last dental visit
Skin

 Scars  Discharges ……………………….

 Hematoma  Others;  Others;

 Lesions
 Hair loss
 Color changes
 Others;  Lumps  Masses  Goiter
Neck

 Normal  Pain  Glaucoma  Flattened neck vessels  Distended neck vessels

 Cataract  Vision problem  Stiffness  Others;
  Glasses  Photophobia  Oedema., Describe;
Eye

Peripheral

Inflammation
vascular

 Infection  Others;  Varicose vein  Pain  Ulceration

 Coldness  Others;
  Cough;  Dry  Wet  Tachycardia  Bradycardia  Murmur
 Color;  Regular  Irregular
 Sputum  Peripheral
 Consistency;  Weak  Thready  Absent
pulse
 Cyanosis  Dyspnea  Orthopnea  Normal 
 Resp. Distress  Hypoxia  Hemoptysis  Capillary refill time  > 2 sec  < 2 sec
Respiratory

  Stridor  Crackles   Heart failure  Heart attack

Heart
Wheezing Chest pain
 Pain  Last CXR or CT-Chest /  Palpitation  Last ECG
 Covid-19  COPD  Asthma  Percutaneous cardiac intervention  Angiography
 Flail chest  Chest  SOB  Rheumatic fever  Congenital heart diseases
trauma
 Others;  Others;

 Urinary  Insertion date; / /  Headache  Seizure  Limb weakness

Neurological system & psychological

catheter  Size;  Tremors  Paralysis  Low back pain
 Urine color ;  Stroke  Fainting  Mood swings
 Dysuria  Nocturia  Retention  Memory problems  Depression  Anxiety
Urinary system

 Hematuria  Urinary  Infection  Hallucination  Aphasia  Facial palsy

Stones
 Incontinence  Burning  Polyurea  Alert  Verbal response
 Conscious level
 Anuria  Urgency  Frequency  Pain responsive  Unconscious
 Postmicturition  Weak  Hesitancy  Others
Dribbling stream
 Others;
  Joint pain  Stiffness  Muscle  DM   Goiter

Endocrine
Heat intolerance
Orthopedic

Cramps
 Backache  Swelling  Limited ROM  Excess sweat  Cold intolerance  Polyurea
 Fracture; site  Menstrual changes  Others;
 Gravida …...  Para  Menopause  Bleeding; site
……...
Genitalia

Blood
 Menstrual  Testicular  Drainage  Anemia; Hb,  Thrombocytopenia  Leukemia
disorders mass
 Lesions  Others;  Thrombocytosis  Transfusion

Health Education Given To Patient

Student Name;

Group;