University of San Carlos

School of Health Care Profession

Department of Nursing
Cebu City

CASE STUDY

I. PATIENT DEMOGRAPHIC PROFILE

Name: Age: Status:
Religion: Occupation:
Nationality: Gender:
Home Address:

II. HEALTH HISTORY PROFILE

A. Past Medical History (include dates, severity, complications if any)
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

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

C. Social and Personal History

1. Occupation

2. Number of Children

3. Foreign travel

4. Habits (tobacco, alcohol, non-prescription drugs, others)

5. Diet

6. Type of Family

7. Cultural and Religious Beliefs

8. Brief Description of Average Day

D. Review of System (for the 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 Discharges Itch Vision Loss Diplopia

Excessive tearing Glasses/Contact Lens Date of Last Exam

Ears Earaches Discharges Tinnitus Hearing Loss

Nose Obstruction Discharges Epistaxis

Throat and Mouth Sore Throat 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 Palpation Dyspnea on Exertion Orthopnea

Paroxysmal nocturnal Dyspnea Edema
Heart murmur Thrombophlebitis Claudication

Gastrointestinal Heart Burn Nausea Vomiting Diarrhea food intolerance

Excessive gas or indication Constipation Jaundice
Change in Bowel Movement Bloating Melena
Hemorrhoids Hernia
Genitourinary Heart Burn Nausea Vomiting Diarrhea food intolerance
Excessive gas or indication Constipation Jaundice
Change in Bowel Movement Bloating Melena
Hemorrhoids Hernia

Extremities Joint Pains Varicose Veins Claudication

Back pains Edema Stiffness Deformities

Endocrine Hot flashes Hair loss Temperature Intolerance

Polydipsia Goiter

Neurology Numbness Tingling Tremor Fainting Headaches

Muscle Weakness Ataxia Unconsciousness Paralysis
Memory loss Dizziness Seizure

Psych Anxiety Depression Sexual Problems Insomnia

Nightmares

Others

III. CURRENT HEALTH PROFILE

A. Presenting complaints and medical diagnosis to include interventions done prior to
hospitalization.
B. Application of the Nursing Process
1. Assessment Findings (Head to Toe)
 2. Laboratory/Diagnostic Results

Date Lab Exam Patient Results Normal Findings Interpretations/

Significant