FLORENCE NIGHTINGALE COLLEGE OF NURSING
GURU TEG BAHADUR HOSPITAL, DILSHAD GARDEN, DELHI – 110095
Case Study/Presentation Format
1. Identification data
Name of Patient:
Age /sex:
Ward/ Bed no:
CR No:
Diagnosis:
Date of admission:
Date& Name of Surgery (If applicable) :
Date of Discharge:
Marital status:
Religion:
Educational Status:
Occupation :
2. Socioeconomic data/Status:
3. History of present illness:
a. Present Medical history and chief complaints
b. Present Surgical history
4. History of past illness:
a. Past Medical history
b. Past Surgical history
5. Family history (medical /surgical) with family tree/ Genogram
Family Composition:
SN Name of Age/ Relation Educatio Occupatio Health
o family Sex with patient n n status
member
6. Personal history (Dietary pattern, sleep & elimination pattern,
Exercise pattern, personal habits, hobbies etc)
7. Physical examination:
Vital signs (3 days)
Head to toe examination
8. Disease process
a. Introduction :
b. Definition of disease /Disorder:
c. Etiology and risk factor (comparative)
Book Picture Patient Picture
d. Pathophysiology:
e. Clinical manifestations (comparative)
Book Picture Patient Picture
f. Diagnostic evaluations(comparative)
Book Picture Patient Picture( write
name of investigation, patient
value , normal value)
g. Medical Management (comparative)
Book Picture Patient Picture
Also write details of drugs including drug name, dosage,
route, action, indications, side effects & nursing
responsibility( in a tabular form)
h. Surgical management (comparative)
Book Picture Patient Picture
i. Nursing management with Nursing care plan (minimum 5
nursing diagnosis as per priority of patient need)
j. Complications (comparative)
Book Picture Patient Picture
k. Prognosis :
l. Progress notes :
Day 1
Day 2
Day 3
o. Health Education:
p. Summary & conclusion:
q. References :
