CASE STUDY

IDENTIFICATION DATA OF PATIENT

 Name of patient : Karunakar Biswal

 Age : 45yr
 Gender :  Male
 Marital Status :  Married
 IPD Number : 260656
 Ward : Neuro surgery HDU
 Bed No : 07
 Address :

 Religion :  Hindu
 Education : Graduate
 Date of Admission : 10/10/2019
 Date of Discharge :
 Diagnosis : AAD(AUTOIMMUNE AUTISTIC DISORDER), with
compression of craniovertebral junction
 Surgery (If any) :
 Occupation : Business

 Chief Complaints with duration:

Patient complains of having inability of feeling legs followed
by arm bilateral since one month. Unable to walk since one month.
 History of present illness: 
Patient was appropropriately alright when started lossing
sensation of his iower limb which started from foot and ascended to the bilateral
upperlimb. Currently patient can not feel all 4 limbs. Patient has lost total power of
lower limbs since 15 days and is unable to walk. Bowel control lost patient gives history
of fall from height one year back after which no treatment was taken.
 History of past illness:No such history found

 Past medical history:

 Past surgical history:

 Family history:
 Type : Nuclear family
 No. of family members: 5
 Any Illness : no

 Family Composition:
Sl Name of the Family Age Relation Education Occupation Health
No Members With Status
. Patient
1. Karunakar 45yr patien graduate business
biswal t

2.

3.

4.

5.

 Family tree:

 History of any Illness:

 Socio-Economic Status:
 Family income : 40,000-80,000
 Enviornmental hygiene: Hygeneic
 Type of house: Pakka
 Personal History:
 Personal hygiene:
 Oral hygiene :Average
 Bath per day :Once a day
 Diet : Mixed Diet
 No. of meals per day :4-5 meals / day
 Food preference :All Type
 Tea/Coffee :Tea
 Sleep & rest :8-10 hrs\day

 Elimination Pattern:
 Bowel :Normal
 Frequency : 1-2 times per day
 Urine frequency
 During day: Irregular
 During Night: Irregular

 Habits:
 Alcohol : No
 Smoking : Yes
 Tobacco : No
 Exercises : Yes

PHYSICAL EXAMINATION
 General Appearance:
 Level of Consciousness : Conscious
 Speech : Clear
 Height : 5’ 6’’
 Weight : 65 kg
 Body Built :Healthy
 Personal Hygiene :Average
 Vital Signs:
Date Time Pulse Respiration Blood Pressure Temperatures
(mmHg)
(°F)
20.11.2019 8AM 78 /M 18 /M 132/80 98.0
9AM 80 /M 20 /M 140/86 98.4
10AM 82 /M 20 /M 136/82 98.4
11AM 82 /M 20 /M 136/80 98.4
12AM 80 /M 18 /M 134/80 98.4
21.11.2019 8AM 76 /M 20 /M 130/86 98.4
 9AM 80 /M 22 /M 130/88 98.2
10AM 80 /M 22 /M 134/88 98.4
11AM 82 /M 22 /M 136/88 98.6
12AM 84 /M 20 /M 140/90 98.6
22.11.2019 8AM 86 /M 20 /M 128/78 98.0

9AM 80 /M 20 /M 130/84 98.2

10AM 80 /M 22 /M 130/86 98.2

11AM 84 /M 20 /M 132/86 98.2
12AM 82 /M 20 /M 130/84 98.4
23.11.2019 8AM 76 /M 20 /M 130/86 98.4
9AM 80 /M 22 /M 130/88 98.2
10AM 80 /M 22 /M 134/88 98.4

11AM 82 /M 22 /M 136/88 98.6

12AM 84 /M 20 /M 140/90 98.6
24.11.2019 8AM 78 /M 18 /M 132/80 98.0
9AM 80 /M 20 /M 140/86 98.4
10AM 82 /M 20 /M 136/82 98.4

11AM 82 /M 20 /M 136/80 98.4

12AM 80 /M 18 /M 134/80 98.4






 Head:
 Size : Normal Size and Shape
 Hair Colour : Black and white mixed
 Scalp : Clean
 Face : Normal
  Facial Symmetry : Symmetrical
 Ears:
 External Ear : Equally distributed position
 Tympanic Membrane : No lesions
 Hearing activity : Normal
 Webber test : Normal
 Nose:
 External Nose : Symmetrical, Nothing abnormal
 Nostrils : No lesion or any discharge
 Sinusitis : Absent
 Sense of smell : Present
 Eyes:
 Eyes Brows : Normal
 Eye Lashes : No lesions present
 Eye Lids : Normal
 Eye Balls : Not sunken or protruded
 Conjunctiva : Transparent
 Sclera : No sign of jaundice and anemia
 Pupils : Reacted to light
 Vision : Normal
 Mouth and Pharynx:
 Lips : Brown in colour, not dehydrated
 Odour : No
 Teeth : 28 in numbers
 Denture : Absent
 Buccal mucosa : Normal
 Tongue : Not dehydrated
 Tonsils : Not enlarged and not swelled

 Neck:
 Lymph Nodes : Palpable
 Thyroid Gland : Not Enlarged
 Range of Motion : Normal
 Cardio-Respiratory System:
 Chest expansion : Expand symmetrically
 Shape : Normal
 Any deformities : No
 Breathing sound : Wheezing Sound
 Respiratory pattern : Difficulty in breathing
 Respiratory rate : 20/min
  Heart :
 Heart sound : S1 and S2 heard
 Murmur sound : No
 Diaphragmatic excursion :
 Varicose vein : No
 Abdomen:
 Inspection :
 Colour of skin : Brown
 Presence of scar : Not present
 Assess for lesions : no lesion present
 Palpation : No tenderness at the area of appendix, no muscle mass
present.
 Percussion :
 Ascites : Not present
 Auscultation :

 Bowel sound : Present

 Genito-urinary system:
 Urinary frequency : Abnormal
 Burning micturation : Present
 Hematuria : No
 Urethral discharge : No
 Bladder tenderness : No
 Musculo-skeletal system:
 Gait : No
 Posture :No kyphosis, lordosis
 Range of motion : Normal
 Spine : Normal
 Weakness : Present
 Integumentary system:
 Skin colour : Normal, brown in color but pale
 Skin texture : Pale, rashes present
 Skin integrity : Normal
 Lesions : Not present
 Cyanosis : No
 Edema : Yes, swelling in hands and feet
 Clubbing of nail : Absent
  Neurological Test:
Station no. Types of exam 3 2 1
A. Mental status examination
1st Level of consciousness:
i. Eye opening 3
ii. Verbal response
iii. Motor response
2nd Observation of poster, body movements, facial
expression dressing grooming, personal 2
hygiene
3rd Observation of speech, mood, feelings, and 2
expressions and thought process and perception
4th Observation of cognitive abilities andmini- 2
mental status examination:
 Assessed orientation
 Assessed concentration
 Assessed recent memory
 Assessed remote memory
 Assessed use of memory to learn new
information
 Assessed abstract reasoning
 Assessed judgement
 Assessed visual perceptual and
constructional ability
B. Cranial nerve examination
5th  Assessed sense of smell 2
 Assessed vision
 4 and 6 assessed pupillary response and
extraocular movement
6th  Assessed motor function, sensory function 3
and corneal reflex
 Assessed motor function and sensory
function
 Assessed hearing and balance
7th  assessed gag reflex and palate movement 2
 Assessed movement of shoulders and head
rotation
 Assessed tongue movement
C.Motor and cerebellar system:
8th  Assessed condition, movement and of 2
muscles
 Assessed strength of muscles
 Assessed balance
 Assessed coordinaion
 D.Sensory function:
9th
 Assessed light touch sensation 3
 Assessed pain sensation
 Assessed temperature sensation
 Assessed vibration sensation
 Assessed tactile discrimination sensation
E.Reflexes:
10th  Biceps reflex 2
 Bracheoradialis reflex
 Triceps reflex
11th  Patellar reflex 2
 Achilles reflex
 Plantar reflex
12th  Abdominal reflex 2
 Test for meningeal irritation
Total: 27
DISEASE DESCRIPTION
 Etiology:

According to book According to patient

 Risk Factors:

Book Picture Patient Picture

  Pathophysiology:

Clinical Manifestations:

Book Picture Patient Picture

 Diagnostic Evaluation:
 Book Picture Patient Picture
Date Investigations Normal value Patient’s Value

 Management:
 Book Picture Patient Picture
DATE Name of the drug Dosage Route Time

Nursing Care Plan

Date Problems Needs Nursing diagnosis according

to priority basis
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to priority basis
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 Health education:
 Progress note:

 Summarization:

 Conclusion:
 Bibliography: