S.

No Student name Medical care plan Surgical care plan

1. Akshaya 1. Dyspnea 1.Emphysema
2. Anemia 2. Peptic ulcer ,
3. Myocardial infraction.
2. Anusha 1. Shock 1. Resp. obstruction
2. Pericarditis 2. Heart block
3. .Renal failure
3. Radhika 1. Bronchitis 1.COPD
2. Pul. TB 2. congestive cardiac failure
3. hyper thyroidsm

4. Pradeepthi 1. Fever 1.lung abscess

2. Pharyngitis 2. cardiomyopathy
3. alopecia
5. Saraswathi 1. Asthma 1 pleural effusion
2. Appendicitis 2.mitral valve stenosis
3. hyperplasia
6. Mousami 1. Empyema 1.rspiratory arrest
2. Esophageal obstructions 2. angina pectoris
3. cellulitis
7. Malathi 1. COPD 1 Hernia
2. Cirrhosis of liver 2.prostities
3. AIDS
8. Gayatri 1. Pneumonia 1pepticulcer
2. Chronic kidney disease 2.Artrities
3.Atherosclerosis

9. Adhilakshmi 1. Sinusitis 1. Appendicitis

2. Pyloric stenosis 2. Endocarditis
3. Alopecia
10. Ester rani 1. Gastritis 1. Arthritis
2. Leukemia 2. Myocarditis
3. Acute renal failure
11. Mounika 1. Peptic ulcer 1. Diverticulitis
2. Resp. arrest 2. Pul .embolism
3. Hyperthyroidism

12. Dhanalakshmi 1. Dialysis 1. Cholilithiasis

2. Nephritis 2. Cardiomyopathy
3. Psoriasis

13. Rahul kondu 1. Appendicitis 1. Lung cancer

2. Heart block 2. Appendicitis
3. Angina pectoris
14. Veranjaneyulu 1. DM 1. Hypo thyroidsm
2. Nephritic syndrome 2. Osteoarthritis
3. Urinary tract infection
15. Nagaraja 1. Pleural effusion 1. Liver abscess
2. Intestinal obstruction 2. Renal calculi
3. meningitis
16. Peraiah 1. Hypertension 1. prostatitis
2. ulcerativecolities 2. meningitis
3. Alopecia
17. Manohar 1. Hypospadias 1. Anal fistula
2. Diverticulitis 2. CCF
3. Bladder cancer
18. Adithya 1. Heap – B 1. Hernias
2. Osteomyelacia 2. Hyperplasia
3. Leukemia’s
19. Murali 1. Epididymitis 1. UTI
2. Mitral valve stenosis 2. Cellulitis
3. Appendicitis
20. Siva prasad 1. Psoriasis 1. Chronic kidney failure
2. Epispadias 2. Cirrhosis of liver
3. Gynecomastia
21. Mahesh 1. Myocardial infraction 1. Bladder cancer
2. Diabetes incipidus 2. Ulcerative colitis
3. Hypothyroidism

22. Sai naik 1. Dyspnea 1. Peptic ulcer

2. Lung cancer 2. Angina pectoris
3. Alopecia
23. Krishna naik 1. Hypotension 1. Cellulitis
2. Dermatitis 2. Empyema
3. Gallbladder cancer
24. Devandra naik 1. Gastritis 1. DM
2. Hepa –B 2. Nephritis
3. Cardiomyopathy
25. Chand basha 1. COPD 1. Hyperplasia
2. Urinary incontinence 2. DM
3. Urethritis
26. Madhu 1. Atherosclerosis 1. Prostatitis
2. Acute renal failure 2. Meningitis
3. Arthritis
27. Chandhu 1. Lung cancer 1. Liver abscess
2. Ulcerative colitis 2. Pul. Edema
3. Paget’s disease
28. Sagar 1. Hernia 1. Shock
2. Cardiomyopathy 2. Pleural effusion
3. Fractures
 29. Vamsi 1. AIDS 1. RESP. obstruction
2. Peptic ulcer 2. Cellulites
3. Hypothyroidism
30. Sanjay 1. Liver abscess 1. Sinusitis
2. Heart block 2. Renal calculi
3. Alopecia
31. Karimulla 1. Laryngitis 1. Heart block
2. Asthma 2. Nephritis
3. Pancreatitis
32. Samuel 1. Psoriasis 1. Appendicitis
2. Hypospadias 2. Endocarditis
3. Pleural effusion
33. Biltu 1. Diarrhea 1. Peptic ulcer
2. Gastritis 2. Pericarditis
3. Intestinal obstruction

34. Souradipdey 1. Emphysema 1. angina pectoris

2. pyloric stenosis 2. renal calculi
3. hyper thyroidism
35. Yallaraiah 1. Hypertension 1. Chronic kidney failure
2. Pneumonia 2. Fractures
3. DM
36. Nagarjuna 1. Leukemia 1. Diverticulitis
2. Hypotension 2. Myocardial infraction
3. Liver abscess

Student profile
Student name;

Name of the college;

Course:

Year of studying:

Topic name;

Date of care started:

Date of care ended:

 Patient’s profile
1. Identification Data:
Client name:
Age/sex:
Father/spouse name:
Hospital registration number:
Ward:
Bed No.:
Address:
Education:
Occupation:
Marital status:
Religion:
Date of admission:
Date of discharge:
Diagnosis:
Surgery (if any):
Date of Surgery:
Doctor In-charge:

2. History of Illness:

• Chief complaints: for e.g. complaints of dyspnoea, low blood pressure and cold and
clammy skin.
• Present medical history: for e.g. complaints of backache, low blood pressure, fever, etc.
• Present surgical history: any history of surgical procedure.
• Past medical history: history of any hypertension, Diabetes mellitus, asthma, COPD or
other disease.
• Past surgical history: history of any surgery in the past.

Family History:
S. No. Name of Age/sex Occupation Relation to Health Education
family family status
members member

Family Tree:

Personal History:
• Dietary habits: vegetarian/ non vegetarian.
• Addiction: history of smoking, drug addiction, alcohol consumption, etc.
• Socio-economic status:

Lab investigations:
 Name of test Normal value Patient value Remarks

Vital Signs:
S. No. Vital signs Normal value Patient’s value Remarks

Medications: trade name, pharmacological name, action, route, dose. Frequency.

Physical Examination
General Appearance:
• Body build:
• Height:
• Weight:
• Vital signs: Temperature:
Pulse:
Respiration:
B.P:
• Colour of skin:
Head:
• Shape and size of skull:
• Scalp:
• Face:
Eyes:
• Vision:
• Eye brow and eyelid:
• Eye ball:
• Conjunctiva:
• Sclera:
• Cornea and iris:
• Pupil:
• Lens:
Ear:
• External ear:
• Tympanic membrane:
• Hearing problem:
Nose:
• External nares:
• Nostrils:
Mouth and pharynx:
• Mouth:
• Teeth:
• Tongue:
• Throat and pharynx:
Neck:
• Thyroid gland:
• Lymph node:
• Range of motion:
Chest:
• Breath sounds:
• Lungs:
• Heart:
Abdomen:
• Inspection:
• Auscultation:
• Palpation:
• Percussion:
Extremities:
• Upper:
• Lower:
Back: assess redness, bed sores, etc.
Genital and rectum:
Systematic examination:
• Central nervous system:
• Sensory system:
• Respiratory system:
• Cardiovascular system:
• Gastro intestinal system:
• Musculoskeletal system:
• Genitourinary system:
• Integumentary system:

ANATOMY AND PHYSIOLOGY: (for e.g. heart)

DISEASE CONDITION: (for e.g.- Aortic stenosis)

Definition:
Etiology:
Pathophysiology:

Clinical Manifestations:
Book Picture Patient Picture
For e.g. Dizziness, fainting Present

Diagnostic Tests:
Book Picture Patient Picture
For e.g. CBC Done

Management:
Medical Management:
Book Picture Patient Picture
For e.g. Antibiotics Given
i.e. vancomycin

Surgical Management:
Book Picture Patient Picture
For e.g. Valve replacement Not done

Complications:

Nursing Process:
Day 1
S. No. Needs Problems

Nursing diagnosis:
Nursing care plan:
Assessment Nursing Goals Interventions Implementations Rationale Evaluation
diagnosis

Nursing Process:
Day 2
S. No. Needs Problems

Nursing diagnosis:
Nursing care plan:
Assessment Nursing Goals Interventions Implementations Rationale Evaluation
diagnosis

Nursing Process:
Day 3
S. No. Needs Problems

Nursing diagnosis:
Nursing care plan:
 Assessment Nursing Goals Interventions Implementations Rationale Evaluation
diagnosis

Nurses notes:

Health education:

Discharge plan:

Conclusion:
During my ________ Clinical Experience, I got a chance to give care to the patient
_________ in ________. Through this case study, I explained about the definition, etiology,
clinical manifestations, investigations,medical and nursing management of the disease condition

Summary:

Bibliography: