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Republic of the Philippines

Bulacan State University

City of Malolos, Bulacan


The Clinical Case Study

In partial fulfilment of requirements in the nursing program, students will be

grouped to collaborate as they compose an investigative and informative report of a
patient’s medical disorder. With the observance of confidentiality, students shall choose
a medical case among their patients in compliance to their clinical case study
presentation. In addition, it is highly recommended that students will only choose
medical disorder that aligns to their level of knowledge and expertise. To ensure that
aforementioned were followed by the students, intelligent advices and supervision by
their clinical instructors during random selection of patients for case study will be
necessary so that students prevent errors and confusions as they go along. Below are
specified steps, contents and tables for a clinical case study chronologically arranged to
guide student researchers.

I. Table of Contents
II. Preliminaries

A. Introduction

The case should begin with a brief passage presenting the patient
by his or her initials, age, medical diagnosis and other related information,
whenever applicable. It then shall document a description of the medical
condition or disease in general that continues and ends up with other
information, such as manifestations, diagnostics and managements, as to
provide readers or listeners a wider understanding and knowledge about
the disease. The body of introduction discusses the information below:
1. Clinical manifestations
2. Diagnostic procedures
3. Medical management (it may include any surgical, pharmacological,
nursing approaches that applies to the study)
4. Evaluation and Prognosis
Lastly, it is also vital that presenters include the disease
epidemiology which denotes local and foreign statistics of disease
occurrence within the last 5 years.

B. Case Objectives
1. General Objective

Prepared by: John Paul E. Mendoza RN, MAN Page 1

Reinforcing Written Clinical Outputs and its Standardization ║ BulSU - CON

2. Client and Student-Specific Objectives (Knowledge-Skills-

Attitude Format)
The client and student-specific objectives must have minimum
of 3 objectives per domain of knowledge, skills and attitude following
nursing principle of SMART.

III. Nursing Health History

A. Biographic Data
1. Name (initials only)
2. Address
3. Age
4. Sex
5. Race
6. Marital Status
7. Occupation
8. Religious Orientation
9. Source of Income (Healthcare Financing and usual source of medical
This initial part of history-taking may have additional information
whenever necessary and applicable. (E.g. pregnancy-related cases are expected
to notate of LMP, AOG, EDC and GPTPAL accordingly; admitting and final
diagnosis may also be included)

B. Chief Complaint or Reason for Clinic Visit

Nurse asks:
1. “What brought you to the clinic or hospital?”
2. “What is troubling you?”
To present a more direct and clearer picture of the patient’s condition, it is
recommended that actual verbalization of the patient is documented in
subjective data format (e.g. “Hirap akong huminga dahil sa matinding sipon
at ubo,” as verbalized by the client).

C. History of Present Illness

1. Ask what is the chronological sequence of events in reference to the
client’s chief complaint:
 When symptoms started?
 How often? Are the symptoms always present or on and off?
 Describe location, intensity and quality of each symptom?
 What are the precipitating and/or aggravating factors?
 What kind of activity the patient was engaging to when
problem occurred?
2. Was help or any medical consultations sought?
3. What home remedies or medications were taken to relieve these
4. Ask how the health problem and its symptoms have interfered with
daily life.

D. History of Past Illnesses

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1. Childhood diseases
2. Immunizations
3. Allergies
4. Accident and Injuries
5. Hospitalizations (This must include any surgical procedures
encountered or previous hospitalizations related to the case being
presented. Preferably, the year patient was hospitalized should be
6. Medications (This should state medications the patient have been
prescribed oftentimes and/or any OTC drugs commonly taken for

E. Family History of Illnesses

1. Illnesses in the family similar to the patient’s
2. Familial incidence of diseases: Diabetes Mellitus, Hypertension with
underlying disorder, Cancer, Mental Illnesses, Rheumatic Fever, Etc.
3. Health conditions and ages of parents, siblings and/or children at
death and its causes
4. Genogram of the patient. A 3rd level generation is the least/minimum
requirement for presentation. See a sample below.

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? age 80 79 77
(Cancer) Hypothyroidism (Heart Failure) Smoker
Obese Type II DM Lumbar disk

58 54 60
65 60 60 Migraines Grave’s disease A&W
HTN MVP Smoker Myopia Hypercholesterolemia
Arthritis HTN

37 32 30

Genogram Key:

= Female
= Male
= Deceased
A & W = Alive and Well
Reference: ( ) = Cause of death
Weber, J. R. and Kelley, J. H. (2014). Health Assessment in
= Adoption
Nursing, Fifth Edition. C & E Publishing Inc. p. 23
= Client

F. Functional Health Pattern

This segment requires presenters to arrange information using a

table which shows a narrative comparison of assessment prior and during
hospitalization. Below are sample table and interview questions for
Functional Health Pattern contents.

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Functional Prior to Hospitalization During Hospitalization

Health Pattern
A. Health
on and
B. Nutritio 72 – Hour Diet Recall 72 – Hour Diet Recall
nal and Day 1 Day 2 Day 3 Day 1 Day 2 Day 3
Metabol Breakfa Breakfa Breakfa Breakfa Breakfa Breakfa
ic st st st st st st
Pattern Lunch Lunch Lunch Lunch Lunch Lunch
Dinner Dinner Dinner Dinner Dinner Dinner

C. Elimina Outp Amo Frequ Charact Outp Amo Frequ Charact

tion ut unt ency eristics ut unt ency eristics
Pattern Urine Urine
Stool Stool

(This table format continues up to Value – Belief Pattern)

F.1 Health Perception and Health Management Pattern

1. How has the general health been for the patient?
2. Are there important health practices he/she always abides to stay
healthy? (This depicts any folk/traditional/home remedies for illnesses;
e.g. cold remedy)
3. Does the patient smoke or drink alcoholic beverages? If yes, quantify.
4. In the past, has it been easy to comply with doctors’ prescription and
nurses’ advices? If any difficulties experienced, specify and explain.
5. If patient had hospitalizations or clinic visits in the past, are there
important issues, suggestions and reminders the patient would like to
raise to improve healthcare delivery? How can nurses be more helpful to

F.2 Nutritional and Metabolic Pattern

1. 3-Day Diet Recall:
a. Typical daily food intake. (This should include vitamins and
supplements, if there is any)
b. Typical daily fluid intake. (For accurate result, this should be
measured in mL)
c. Analysis and Interpretation

2. Ask how the patient describes his/her appetite.

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3. Ask if patient experiences eating discomfort or is currently on specific

diet restrictions. (E.g. dental problems, low fat diet)
4. Interview for weight gain or weight loss.
5. Know if patient has wound healing issues.

F.3 Elimination Pattern

1. Urinary/Bowel Elimination Pattern. It discusses frequency, amount,
color, discomfort and other characteristics on urination and defecation.
2. Analysis and Interpretation for the table presented.
3. Also, it may discuss other elimination-related concerns if necessary.
(E.g. hyperhidrosis or excessive perspiration)

F.4 Activity – Exercise Pattern

1. Discuss and describe the Patient’s Activities of Daily Living (ADL)
2. Is energy sufficient to sustain daily activities?
3. Leisure activities and child-play activities, if appropriate.
4. Perceived Ability to Perform ADL (Graded by Level):

____ Feeding ____ Bathing ____ Toileting ____ Bed Mobility

____ Dressing ____ Grooming ____ Cooking ____ Home Maintenance
____ Outdoor Activities (E.g. Shopping) ____ General Mobility

Suggested Functional Level Classification:

Level 0 – Full Self Care or Completely Independent
Level I – Requires use of equipment or device
Level II – Requires help from another person for assistance, supervision,
or teaching
Level III – Requires help from another person and equipment device
Level IV – Dependent, does not participate in activity

F.5 Sleep – Rest Pattern

This portion discusses:
1. Approximate hours of sleep at night
2. Sleep characteristics (if continuous or not; if with sleeping difficulty)
3. Is there a need for sleep-inducing medications?
4. Does the patient feel rested after waking?
5. Is the patient taking naps in the afternoon? If yes, how long?
6. Relaxation habits (watch movie, reading books, dancing, shopping,

F.6 Cognitive – Perceptual Pattern

It presents:
1. Sensory status (visual, auditory, olfactory, gustatory issues; balance
and muscle coordination)
2. Use of eyeglasses, hearing aids and previous checkups
3. Memory status (memory losses, if one has)
4. Learning Strategies (if the patient understands things better by
reading, listening, or in other ways of learning)

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5. Perception of pain (case-to-case basis, pain tolerance and threshold

may need to be discussed)

F.7 Self- Perception and Self-Concept Pattern

1. A nurse may ask: “How do you describe yourself? Do you feel good
about yourself?”
2. How the patient see the physical changes in his/her body and changes
on activities he/she usually does. (This may apply on cases that
dramatically affect one’s body image. E.g. Amputation of limb)
3. What are the things or situations that easily make the patient angry,
annoyed, fearful, anxious or depressed? What helps him/her to cope
with these?

F.8 Role – Relationship Pattern

1. Is the patient living alone? If living with his/her family, describe their
family structure and availability of support system.
2. Common family problems and how these were handled
3. Issues with dependent member in the family and how these get
managed, if applicable.
4. If appropriate, how do significant others feel about the illness and/or
5. Problems encountered within social groups, close friends, workplace.

F.9 Sexuality – Reproductive Pattern

1. If appropriate, discuss any changes or problems in sexual relations
2. If appropriate, inquire about use of contraceptives and family
3. If appropriate, include menarche, LMP, menstrual problems, and
pregnancy-related concerns.

F.10 Coping – Stress Tolerance Pattern

A nurse may ask:
1. Tense a lot of time? What helps? Use of any medicine, drugs or
2. Who’s most helpful in overcoming life stresses? Are they available at
all times?
3. Any big changes which put an impact to your life in the last year or
4. How do you handle life stressors? Is your coping mechanism found to
be effective?

F.11 Value – Belief Pattern

1. It discusses things or relations patient value the most.
2. Religion and religious practices.
3. It discusses how the patient sees his/her spiritual being and how one’s
belief help or interfere in any health-related matters.

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IV. Growth and Development

In able to present a client-specific discussion, it is a requirement that
students focus only on developmental stage where patient may be
categorized. A table below serves as your guide.

Theory Erik Sigmund Jean Piaget’s Kohlberg’s Fowler’s

Erickson’s Freud’s Cognitive Moral Spiritual
Psychosocia Psychosexu Development Developme Developme
l al Theory nt Theory nt Theory
Developme Developme
nt Theory nt Theory

al Stage

V. Nursing Theory Application

Discussion of nursing theory should only mention topics, theories or
models that will apply to the patient’s condition. See table below for

Theory Theorist Description Application of

Theory to the Patient

Health Promotion Nora J. Pender

Self – Care Deficit Dorothea Orem

VI. Anatomy and Physiology

As to adhere in a client-centered discussion of the study, anatomy and
physiology shall focus on the affected anatomical features and functions only.
(E.g. Meningitis may discuss the normal meningeal layers and its functions
Illustrations will be substantive as well so long it focuses on the affected
body areas only.

VII. Pathophysiology
This segment of the study briefly defines the disease process the client has
encountered. Following a sentence or passage of description, it will discuss
the entire mechanism of the disorder using a schematic diagram that begins
with risk factors contributing to the occurrence of a disease – modifiable and
non-modifiable causative factors. Sometimes the identification of one or two
risk factors as either modifiable or non-modifiable may vary from one patient

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to another (e.g. stress). Furthermore, the diagram continues to go down

following arrowed lines that navigates to explain the whole disease process
until each branch ends up with the patient’s clinical manifestations. See a
sample diagram below.

Pathophysiology of Type II Diabetes Mellitus

Modifiable Risk Factors Non-Modifiable Risk Factors

Lack of Smoking Obesity Gender Stress Age

Exercise (Female)

↑ Insulin ↑ Free fatty Induce release ↓ Insulin

Poor glucose Resistance acids ↑ Adipose of Sensitivity
metabolism deposits by glucocorticoids
Adiposity anatomical and other stress
blocks nature hormones
↑ Glucose synthesis



↑ Blood osmolarity ↑ Blood viscosity

ICF dehydration ↑ Osmotic pressure on ↓ Tissue perfusion

the renal tubules

Thirst sensation
Poor wound healing Poor O2 and nutrient
Osmotic diuresis supply of the body cells
Polyuria Cell starvation

Weight loss

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VIII. Physical Assessment

One must bear in mind that normal findings may vary from one patient to
another due to physiologic changes or developmental milestones for all
individuals (e.g. Posture for pregnant women normally shows lordotic
appearance). In addition, the physical assessment table requires additional
information such MMDST and APGAR scoring for pediatric clients whenever
applicable. Moreover, each finding of deviation from normal must reflect
scientific analysis and interpretations. Lastly, PA table shall end with
summary of significant findings.
A physical assessment table is provided for your guidance.

IX. Diagnostic (Laboratory and/or Radiologic) Procedures

Procedure Date Indicatio Actual Normal Analysis Nursing

Rendere n and Values/ Values and Responsibilit
d Purpose Results Interpret ies
1. Hematolog Prior:
y (sample During:
only) After:
2. Chest X-ray Prior:
(sample During:
only) After:
Gentle reminder, contents of the table above for presentation must deliver
data that directly relates to the patient only. Likewise, each procedure done
must be arranged chronologically according to the date it was ordered.

X. Medical-Surgical Management

A. Palliative (Supportive) Management

Medical Date General Indicatio Client’s Nursing
Procedures Ordered/ Description n/ Respons Responsibiliti
Taken/ (Classificatio Purpose e es
Changed/ n/
Discontinue Actions)
1. IVFs Prior:
(sample During:
only) After:
2. Oxygen Prior:
Therapy During:
(sample After:
Others Prior:

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Gentle reminder, contents of the table above for presentation must deliver
data that directly relates to the patient only. Likewise, each procedure done
must be arranged chronologically according to the date it was ordered.

B. Surgical Management
Surgical Procedures Date General Client’s Nursing
Performed Description Response Responsibilities
1. Appendectomy Prior:
(sample only) During:

C. Drugs
Medicat Date Route of Mechan Indicatio Contrai Client’s Nursing
ion Ordere Admini ism of n ndicatio Response Responsibi
d/ stration/ Action n lities
Given/ Dosage/
Taken Frequen
Generic: [This Prior:
Brand: shall During:
Classific both After:
ation: desired
(side and
on drugs]
Gentle reminder, contents of the table above for presentation must deliver
data that directly applies or relates to the patient only. Likewise, each
medication must be arranged according to the date it was ordered, i.e. in
chronological order.

D. Diet
Type of General Indication/ Specific Client’s Nursing
Diet Description Purpose Foods Response Responsibilitie
Taken s

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E. Exercise
Type of General Indication/ Client’s Nursing
Exercise Description Purpose response Responsibilities

XI. Nursing Management

A. Nursing Problem Prioritization

Level Date Cues Nursing Diagnosis Justification / Bases
of Identified in Prioritizing the
Priorit Problem


B. Nursing Care Plan

Assessment Nursing Planning Intervention Rationale Evaluation
Subjective: Short Term Independent: Short Term
Goal: Eval:
Objective: Dependent:
Long Term Long Term
Goal: Interdependent Eval:

Presenters may be advised to develop more than 3 nursing care plans

since frequency of identified health issues per disease vary in every patient but in
order to timely manage and deliver case presentations, a discussion for
minimum of 3 nursing problems during case presentations is acceptable.

XII. Discharge Planning

M Medicines (Take
Home Meds)
E Exercise
T Treatment
H Health Teaching
(and/or Hygiene)
O Outpatient Care
D Diet
S Spiritual (or Sexual

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XIII. Conclusion

This portion shall comply and be congruent to the enumerated general

and specific objectives of the study.

XIV. Bibliography

List each source/reference following the APA format. Samples of

documenting book and online resources are shown below respectively.

Kozier, B. &Synder S. (2008) Fundamentals of Nursing: Concepts, Process &

Practices. (8thed). Philadelphia: Prentice Hall.

Landsbergis, P.A., (2006). Occupational Stress among Health Care Workers:

A Test of the Job Demands-Control Model, Journal of Organizational Behavior
Volume 9, Issue 3, pages 217–239, Retrieved from

XV. Grammar/Margins/Fonts/Other Formatting Concerns

Since clinical case study serves as one of the prime examples of nursing
researches, students must narrate their study using third person point of view. (E.g.
“Nursing students” or “researchers” as sentence subjects, instead of saying “I” or
For typing and printing concerns, please observe the following:
 Font Style: Times New Roman
 Font Size: 12
 Margins: 1 inch in all borders
 Front Page: (See samples attached)
 Header: (Title of the Clinical Case Study) + BulSU – CON
Place at right top corner
E.g. Lobar Pneumonia ║ BulSU – CON
 Footer: Page numbers only.
E.g. Page 3 of 38
 Binding: Hard – Binding
 Color: Royal Blue
 Additional sample templates attached herewith

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