HEALTH EDUCATION

CASE PRESENTATION

PATIENT BIO DATA

Name : __________________________________________

Age : __________________________________________

Sex : __________________________________________

IPD no : __________________________________________

Address : __________________________________________

Occupation : __________________________________________

Religion : __________________________________________

Marital status : __________________________________________

Date of admission : __________________________________________

Date of discharge : __________________________________________

Diagnosis : __________________________________________

Dr. Consultant : __________________________________________

CHIEF COMPLAINTS :
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

HISTORY:

 Past medical:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
 Past surgical:
________________________________________________________________________
________________________________________________________________________
 ________________________________________________________________________
________________________________________________________________________
 Present medical:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
 Present surgical:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

FAMILY HISTORY

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

FAMILY TREE
SOCIO-ECONOMIC STATUS

 Monthly income : _____________________________________________

 House : _____________________________________________
 Disposal of waste : _____________________________________________
 Drinking water : _____________________________________________
 Pets : _____________________________________________

PERSONAL HISTORY

 Sleeping pattern : _____________________________________________

 Eating pattern : _____________________________________________
 Addiction : _____________________________________________

PHYSICAL EXAMINATION

 Head
- Hair & scalp : _____________________________________________
- Eyes : _____________________________________________
- Nose : _____________________________________________
- Mouth : _____________________________________________

 Neck : _____________________________________________

 Chest
- Inspection : _____________________________________________
- Palpation : _____________________________________________
- Percussion : _____________________________________________
- Auscultation : _____________________________________________

 Back : _____________________________________________

 Genitals : _____________________________________________
 Limbs
- Upper limbs : _____________________________________________
- Lower limbs : _____________________________________________
DIAGNOSTIC TESTS:
IN BOOK IN PATIENT

ETIOLOGY:
IN BOOK IN PATIENT
CLINICAL MANIFESTATIONS:
IN BOOK IN PATIENT

MANAGEMENT:

 MEDICAL MANAGEMENT :
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
 SURGICAL MANAGEMENT:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
 PHARMACOLOGICAL MANAGEMENT:
NAME DOSE ROUTE ACTION SIDE-EFFECT NURSING
RESPONSIBILITY
 CASE STUDY

PATIENT BIO DATA

Name : __________________________________________

Age : __________________________________________

Sex : __________________________________________

IPD no : __________________________________________

Address : __________________________________________

Occupation : __________________________________________

Religion : __________________________________________

Marital status : __________________________________________

Date of admission : __________________________________________

Date of discharge : __________________________________________

Diagnosis : __________________________________________

Dr. Consultant : __________________________________________

CHIEF COMPLAINTS :
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

HISTORY:

 Past medical:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
 Past surgical:
________________________________________________________________________
________________________________________________________________________
 ________________________________________________________________________
________________________________________________________________________
 Present medical:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
 Present surgical:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

FAMILY HISTORY

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

FAMILY TREE
SOCIO-ECONOMIC STATUS

 Monthly income : _____________________________________________

 House : _____________________________________________
 Disposal of waste : _____________________________________________
 Drinking water : _____________________________________________
 Pets : _____________________________________________

PERSONAL HISTORY

 Sleeping pattern : _____________________________________________

 Eating pattern : _____________________________________________
 Addiction : _____________________________________________

PHYSICAL EXAMINATION

 Head
- Hair & scalp : _____________________________________________
- Eyes : _____________________________________________
- Nose : _____________________________________________
- Mouth : _____________________________________________

 Neck : _____________________________________________

 Chest
- Inspection : _____________________________________________
- Palpation : _____________________________________________
- Percussion : _____________________________________________
- Auscultation : _____________________________________________

 Abdomen
- Inspection : _____________________________________________
- Palpation : _____________________________________________
- Percussion : _____________________________________________
- Auscultation : _____________________________________________

 Back : _____________________________________________
  Genitals : _____________________________________________
 Limbs
- Upper limbs : _____________________________________________
- Lower limbs : _____________________________________________

ANATOMY & PHYSIOLOGY:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
DIAGNOSTIC TESTS:
IN BOOK IN PATIENT

ETIOLOGY:
IN BOOK IN PATIENT
CLINICAL MANIFESTATIONS:
IN BOOK IN PATIENT

MANAGEMENT:

 MEDICAL MANAGEMENT :
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
 SURGICAL MANAGEMENT:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
 PHARMACOLOGICAL MANAGEMENT:
NAME DOSE ROUTE ACTION SIDE-EFFECT NURSING
RESPONSIBILITY