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CASE PRESENTATION
1. Patients Biodata:

 Name: ____________________________________________________________
 OPD No: ____________________________________________________________
 IPD No: ____________________________________________________________
 Age/Sex: ____________________________________________________________
 Address: ____________________________________________________________
 Marital Status: ______________________________________________________
 Educational Status: ________________________________________________
 Occupation: ______________________________________________________
 Family Income: ______________________________________________________
 Source of Health care: ________________________________________________
 Date of admission: ________________________________________________
 Diagnosis: ______________________________________________________
 Name of Surgery: ________________________________________________
 Date of surgery (If done): __________________________________________
 Date of discharge:. ________________________________________________

2.Present complaints: ___________________________________________________________________

_____________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

3.History of Present illness:

Onset: __________________________________________________________________________

Symptoms:_________________________________________________________________________

__________________________________________________________________________________

Duration:__________________________________________________________________________

Precipitating factors: ______________________________________________________________

Any other : ___________________________________________________________________

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4 . History of past illness:

Illness: __________________________________________________________________________

Surgeries: __________________________________________________________________________

Allergies: __________________________________________________________________________

Immunizations: ____________________________________________________________________

_________________________________________________________________________

Medications: ____________________________________________________________________

__________________________________________________________________________

Any Other:__________________________________________________________________________

5. Family History- Family Tree:-

6. Personal Habits:-

Consumption Of Alcohol: ______________________________________________________

Smoking: ________________________________________________________________________

Tobacco Chewing: ____________________________________________________________

Sleep: ________________________________________________________________________

Exercise And Work: _______________________________________________________________

Elimination: __________________________________________________________________

Nutrition: ________________________________________________________________________

Any Other: _______________________________________________________________________

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7.Physical examination with date & Time:

8.Investigation:

Normal Value
S. No Name of investigation Patient Value
(with unit)
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9. Diagnostic Tests & Procedures:

S. No. Date Name of test Impression

10 . Definition and Description of disease: _____________________________________________

______________________________________________________________________________

_____________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________
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11.Risk factor & causes:

S.
According to book Patient’s picture
No.

12.Clinical features :

S.
According to book Patient’s picture
No.
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13.Brief Pathophysiology:
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14.Management:

S. No. According to book Plan for patient

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15. Treatment:

Name of drug
S. No Action
(Trade & Chemical name)

16. Any other management (if surgery done):

 Type of Anesthesia: __________________________________________________________

 Pre operative diagnosis : ____________________________________________________________

post operative diagnosis : ____________________________________________________________

 Brief description of surgery: ________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

 Post operative orders: ______________________________________________________________

___________________________________________________________________________________

__________________________________________________________________________________

___________________________________________________________________________________

17. Dietary Management (Daily): ________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________
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______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________
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18. Nursing management:

Nursing Process:

Objective/
S. Nursing
Assessment expected Intervention Rationale Evaluation
No. Diagnosis
outcome
1. Subjective data:

Objective data:
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Objective/
S. Nursing
Assessment expected Intervention Rationale Evaluation
No. Diagnosis
outcome
Subjective data:

Objective data:
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19. Health Education:

20. Conclusion:

21. Bibliography: