CASE STUDY FORMAT

I. PATIENT DEMOGRAPHIC PROFILE

Name: ____________________________ Age/Gender:_______ Status:_______

Home Address: ____________________________________________________
Religion: ____________ Nationality:___________ Occupation:______________

II. HEALTH HISTORY PROFILE

A. Past Medical History

1. Pediatric and Adult Illness

Date Illness Medication Remarks

2. Immunization

Immunization Doses Dates Remarks

3. Hospitalization

Date/Year Hospital Diagnosis Duration

4. Injuries and Accidents

5. Transfusions
 6. Allergies (specify)

B. Family History (support with genogram and limit to two (2) generation if patient can recall)

C. Social and Personal History

1. Occupation
2. Number of Children
3. Military experience, foreign travel
4. Habits
5. Diet
6. Type of Family
7. Cultural and Religious Beliefs
8. Brief description of average day

D. Review of System (for past 6 months). Physical Assessment

General Weight loss Fatigue Anorexia Night Sweats Chills Fever

Weakness

Skin Itch Rash Lesions Bruising Bleeding Color Change

Eyes Pain Discharge Itch Vision loss Diplopia Excessive tearing

Glasses/contact lens Date of last exam

Ears Earaches Discharge Tinnitus Hearing loss

Nose Obstruction Discharges Epistaxis

Throat and Mouth Sore throats Bleeding gums Toothache Dentures

Neck and Head Swelling Dysphagia Hoarseness

Chest Cough Sputum: Amount and Character Hemoptysis Wheeze Pain on

respiration Dyspnea

Cardiovascular Precordial pain Palpitation Dyspnea on Exertion Paroxysmal nocturnal dyspnea

 Orthopnea Edema Heart murmur Thrombophlebitis Claudication

Gastrointestinal Nausea Vomiting Diarrhea Food Intolerance Excessive gas or indication

Constipation Change in bowel movement Jaundice Bloating Melena
Hemorrhoids Hernia

Extremities Joint pains Varicose veins Claudication Back Pain Edema Stiffness Deformities

Endocrine Hot flashes Hair loss Temperature intolerance Polydipsia Goiter

Neurology Numbness Tingling Tremor Fainting Headaches Muscle weakness Ataxia

Unconsciousness Paralysis/ paresis Memory loss Dizziness Seizure

Psych Anxiety Depression Sexual problems Insomnia Nightmares

III. CURRENT HEALTH PROFILE

A. Presenting complaints and medical diagnosis to include intervention done prior to

hospitalization
B. Application of the Nursing Process
1. Assessment Findings (Head to Toe)

Body Parts / Technique Actual Normal Findings Interpretation

Findings
Head
Proportion to the size of the
body, round, with
1.Skull
prominences in the frontal
Palpation
area interior and the occipital
Size, shape or contour, symmetry
are posterior, symmetrical in
and curvature.
all planes, gently curved.

2.Scalp
Inspection
Carefully separate the hair at White, clean, free from
various locations. masses, lumps, scars, lice,
nits, dandruff, and lesions.
Inspect for color, appearance,
and presence of masses, lice nits,
and dandruff.

Palpation No areas of tenderness.

Areas for tenderness

3.Hair
Inspection Black evenly distributed and
Inspect for the color, covers the whole scalp, thick,
 distribution, thickness, and shiny and free from split ends.
lubrication or appearance.

Palpation Coarse of fine

Palpate for texture

4.Face
Inspection
Observe for the symmetry,
shape, facial expression,
movement and appearance.
Oblong or oval or round or
square or heart-shape,
symmetrical, facial expression
that is dependent on the
mood or true feelings, smooth
and free from wrinkles and no
involuntary muscle
movements.

5.Eyes
Inspection Observe for
Parallel and evenly placed,
placement, symmetry,
symmetrical, non protruding,
protrusion, clarity, and
with scant amount of
lacrimations.
secretions, both eyes bright
and clear.
*Eyebrows
Inspection
Observe for color, symmetry,
Black, symmetrical, thick,
and quantity of hair, distribution
raise and lower symmetrically,
and placement unparallel.
evenly distributed and parallel
with each other.
*Eyelashes
Inspection
Black evenly distributed and
Observe for the color,
tuned outward.
distribution
and direction

*Eyelids
Upper lid covers a small
Inspection
portion of the iris and the
Ask the client to close eyes.
cornea and sclera when the
eyes are open. When the eyes
Observe for position and
are closed---the symmetrical
symmetry and then ask him to
open eyes again.

Palpation
Non-palpable, non tender.
Using the tip of the index finger,
palpate the lacrimal gland.

Salmon pink, shiny, moist.

*Lower palpebral conjunctiva
Inspection
Ask the client to look up and pull
the lower lid down,
Observe for color and
appearance.
White and clear, no visible
*Sclera
blood vessels.
Inspection
 Color and clarity

*Cornea
Inspection Transparent, shiny, smooth.
Clarity and texture

*Pupils Round, equal constrict when

Inspection light is pointed to the eyes
Size, shape, symmetry, reaction and dilated when light is
to light and accommodation. removed, constrict when
object is close to the eyes and
dilated when object is
removed away.

Iris
Inspection Proportional to the size of the
Size, color, shape eyes, round, black brown,
symmetrical.

*Testing for eye movement

Inspection
Stand directly in front of the
client and hold the finger at
about one foot in front of the
client’s eyes.
Able to move eyes in full
ranges of motion or able to
move in all direction.

Able to see 60 degrees

Ask the client to refrain from superiority.
moving his head and follow the
direction of the examiner’s
fingers with his eyes only. Move
the finger in a slow manner Midline, symmetrical and
though the cardinal fields of patent.
gaze.

*Testing for visual fields

Inspection
Stand 2-3 ft. from the client. Ask Able to repeat the words
(one ear at a time and then at
the back of the client for both
ears).

Instruct the client not to move

his head and to repeat the words
that you will say.

6.Nose
Inspection In the correct placement,
Placement, symmetry and Patent and symmetrical
patency.

*Internal nares
Inspection
Appearance, color of mucus Clean, pinkish, with few cilia.
membrane, presence of cilia.
 *Septum
Inspection Straight.
Appearance

7.Mouth

*Lips
Pinkish, symmetrical with lip
Inspection
margin well defined, smooth
Observe for color, shape,
and moist.
symmetry, lip margin and
appearance

Pinkish, smooth, moist, no

*Gums
reseeding, no swelling and no
Inspection
discharge
Observe for color, appearance,
discharge and swelling or
contraction.
32 permanent teeth, well-
*Teeth
aligned, free from caries or
Inspection
filling and no halitosis.
Number, color, alignment,
general condition, breath
Large, medium, red or pink,
*Tongue
slightly rough in top, smooth
Inspection
along the lateral margins,
Inspect for size, color, surface,
moist shiny and freely
appearance and movement
movable.

*Frenulum
Midline, straight end thin
Inspection
Position and appearance

*Checks
Pinkish, moist and smooth
(buccal mucosa)
Inspection
Color and appearance

8.Palate

*Soft palate Pinkish, moist, smooth

Inspection
Color and appearance

*Hard palate Slightly pinkish

Inspection
Color and appearance.

*Uvula At the center

Inspection Symmetrical and freely
Position, color, size, symmetry, movable
And mobility
 *Tonsils
Inspection Pinkish, non-inflamed
Detect if there is hoarseness
of voice

9.*Neck Proportional to the size of the

Inspection body and head, symmetrical
Size, symmetry, position and straight.

*Palpation
Palpate for lumps, masses or No palpable lumps, masses or
areas of tenderness areas of tenderness

Palpates the Adam’s apple (for male) Palpable

Freely movable without

Range of motion difficulty
Chin to chest
Ear to shoulder

Muscular strength Symmetrical and able to resist

Inspection applied force(both muscle)
Symmetry and strength of the
sternocleidomastoid muscle

Able to resist applied force

Force/strength of the trapezius symmetrical in structure of
muscle size and muscular strength

10. Thorax
The chest contour is
symmetrical and the chest is
(Anterior and posterior)
twice as wide as deep
Inspection
(anteriposterior diameter in a
Have the client all comfortably.
1:2 ratio) the spine is straight
Inspect for the shape, position of the
posteriorly, the ribs tend to
spine, slope of the ribs, retraction of
slope across and down the
the intercostals spaces (ICS) on the
ribs are prominent in a thin
inspiration, and bulging of the ICS on
person there is no bulging or
experimentation.
retraction of breathing.

The chest wall moves

symmetrically during
respiration
Observe for symmetry of the chest
wall during respiration

No lumps, masses, areas of

Palpation
tenderness sides of the thorax
Palpate for lumps, masses, areas of
expand symmetrically. the
tenderness.
examiners thumb separate
approximately 2 inches
Measure chest excursion (to
determine the depth of breathing). during breathing
Place hands on the lower portion of
the rib cage with the thumbs 2
inches apart pointing toward the
spine so a small fold of the skin
appears between the thumbs.

Ask the client to take a few deep

breaths.

Elicit lacille fromitus (a thrill felt by The vibrations are feeling

the hand on the chest wall while the most strongly between the
client is speaking). Place the palms first and second ribs along the
of the hands bilaterally symmetrical sternum interiorly and
on the chest. Start from the top of between the scapulae
the chest wall going down .each posteriorly.
time the hands move down, ask the
client to say ninety-nine or one-one
–one with the same intensity of
voice.

Percussion:

Anterior thorax. The client is

preferably in a lying position.

Posterior thorax. The client is sitting

position with the arms folded
forward across the chest. This
position will separate scapulae
further to expose more lung to
assessment.
Using the direct percussion, percuss
in the ICS over symmetrical areas of
the chest starting from the
supraclavicular area. Compare one
side of the chest with the other.
Vesicular sounds are heard
over lung periphery
particularly at the base of the
lungs, they are soft intensity,
low pitched gentle sighing
sounds created by hair
moving through smaller
airways bronchovessicular so
this are heard at the 1st and
2nd IC at the sternum interiorly
and between the scapulae
posteriorly

Auscultation:

Use the flat-disc diaphragm. Use No pulsations.

the systematic zigzag procedure
used in percussion. Ask the client to
take slow deep breaths through the
mouth. Listen at each point to the
breath sounds during a complete
respiration. Compare findings at
each point on the opposite side of
the chest.
 *Heart
Pulsations visible and palpable
Inspection and palpation:
Place the client in supine position.
Stand in the client’s right side. Ask
client not to talk. Inspect and
palpate the valve areas of the heart.

Abdominal aortic pulsation

*Aortic areas visible and palpable.
Around at the 2nd ICS on the right
angle of
Louis as a dominance on the The 2 heart sounds are
Sternum audible in all areas but
loudest at apical area..
*Pulmonic Area- at the 2nd ICS on the
left of Louis.
Note: Observe these areas at an CR ranges from 60-100 beats
angle to the side to improve the per minute.
chance of seeing pulsations.

*Tricusspid Area – move the fingers

along the client’s left sternal border
to the 5th ICS. Females: variable in size
depending on body build,
rounded shape, symmetrical
*Apical Area – moves the fingers
laterally to the left mid-clavicular
line (LMCL), which is slightly below Males: Flat, symmytrical, if
the nipple. This point where the obese, may be slightly
apex touches the anterior chest wall rounded.
is known as the point of maximal
impulse (PMA)

*Epigastric Area – at the tip of the

sternum.

Auscultation: Auscultate the hearth

in all 4 anatomic sites: aortic,
pulmonic, tricuspid and apical
(mitral)
Eliminate all sources of room noise.
Heart sounds are of low intensity
and other noise hinders the nurse’s
ability to hear them.

Identify the first sounds described

and “lub”. Then, identify the 2nd
sound. This is higher – pitched that
SI, described as “dub”

Use the bell-shaped diaphragm.

Once SI and S2 are identified, count
the heart rate for one minute. Each
combination of S1 and S2 counts as
one heart beat.
 11.Breast

Inspection
Ask the client to remove the top
gown or drape to allow
simultaneous visualization of the
breast. Have the client sit
comfortably with arms at the sides.
Inspect the breast for size, symmetry
and contour or shape.

Skin is the same in color in the

Inspect the skin of breast for color, abdomen, no retractional
retraction, or dimpling. dimpling.

Palpation
Assist the client in supine position.
This position allows the breast No masses or lumps,
tissues to flatten evenly against the tenderness, breast tissues are
chest wall facilitating palpation. Ask firm and elastic.
client to false his/her hand and place
it under the head palpate the breast
for lumps or masses, tenderness,
and consistency of breast tissues.
The palmar surface of the first three
fingers is used to compress breast
tissues against the chest wall.
Perform palpation in a clockwise
rotary motion from the borders
going inward.

*Areola Round or oval, color darker

Inspection that surrounding skin,
Inspect for size, shape, color and symmetrical
summetry.

No masses and tenderness.

Palpation
Palpate for masses and tenderness

*Nipples
Round, averted, equal in size,
similar in color. Both nipple
Inspection points in one direction, no
Inspect for size, shape, position, discharge, no lesion
discharge and lesions.

No masses, tenderness and

Palpation discharge.
Use thumb and index finger to
compress the nipple to determine
any discharge.
 12.Abdomen

Divide the abdomen into 4 imaginary

quadrants. Draw a vertical line from
the xipoid process to the symphysis
pubis and a horizontal line across
the umbilicus. These quadrants are
labeled right upper quadrants
(RUQ).left lower quadrants (LLQ),
and right lower quadrant (RLQ)
Ask the client if he/she needs to
void. Drape the upper chest and
legs. Explore the abdomen from the
xipoid process to the symphisis
pubis. The client lies in supine
position with arms down at the
sides. A small pillow may be placed
under the head. Skin is unblemished, no scars,
color is uniform, flat, rounded
or scapoid, symmetrical
Inspection movement caused by
Inspect the abdomen for skin respiration, nortic pulsation at
integrity, color, contour, symmetry, epigastric are visible thin
movement or pulsations and color persons, umbilicus is flat or
and placement of umbilicus. concave positioned midway
between the xipoid process
and the symphisisd pubis,
Auscultation color is the same as the
Warm the diaphragm of the surrounding skin.
sytethoscope. Cold stethoscope may
cause the client to contact the
abdominal muscles and the
contractions may be heard during
auscultation. Diaphram is used
because intestinal sounds are high
pitched sounds. Place the diaphragm
in each of the 4 quadrants over all
auscultation sites. It may take
minute to hear bowel sounds.

Palpation
Perform light palpation first to
detect areas of tenderness, muscle
guarding (voluntary tightening of
muscles), lumps or masses,
constancy, and organomegaly.

Depress the abdominal wall lightly,

about 1 cm with the pads of your
fingers. Move the finger pads in a
sight circular motion. Palpate all 4
quadrants.

Palpate the liver using deep Liver’s edge feels firm and
palpation. Stand on the client’s right non-tender
side. Place your left hand on the
posterior thorax at about the 11th
and 12th rib and then apply upward
 pressure. This maneur makes it
easier to feel the liver anteriorly.
With the fingers of the right hand
pointing upward, place the hand on
the RUQ well below the liver’s lower
border, then press gently until you
reach a depth of 1 ½ - 2 inches. Ask
the client to take a deep breath
using the abdominal muscles. As he
inhales, try to palpate the liver’s
edge as it descends.

Percussion Tympanic ground

Percuss each of the 4 quadrants
starting from the RUQ going
clockwise.
predominated because of the
air in the stomach and
intestines. Percussion sound is
dull at the liver’s lower
portion.

*Wrist

Ask the client to flex and extend Perform with ease

hands at the wrist and then perform
radial and ulnar flexion.

*Hands and fingers Perform with ease

Ask the client to do flexion,

extension, abduction of fingers,

13.Lower Extremities
Symmetrical in size and
length, no abnormalities, fine
Inspection hair equally distributed, no
Inspect for symmetry of size and visible varicose vein
length and the presence of
abnormalities. Note the pattern of
hair distribution, color and presence
of varicose veins.

Palpation Warm and smooth

Palpate from thighs to logs for
temperature, and texture.

*Feet and Toes Clean no lesions, 5 toes on

each foot.
Inspection
Inspect for cleanliness, skin lesion
and number of toes

*Hips
Performs with ease
*Range of Motion
Ask the client to do flexion,
 extension, abduction, adduction,
and internal external rotation of the
legs
Performs with ease
*Knees
Ask the client to flex and extend
each leg

*Ankle Performs with ease

Ask the client to do flexion,
extension, aversion, and inversion of
each foot.

Performs with ease

*Foot and Toes
Ask the client to flex, extend, abduct
and adduct toes

Laboratory/Diagnostic Results
Date Lab exam Patient result Normal Interpretation/
Findings Significant

2. NCP
3. Drug Study
4. Discharge Plan (M-E-T-H-O-D-S)