This document outlines the sections and format for a case study report, including: 1) The patient's profile and medical history 2) Assessment of the patient's physical and mental health patterns 3) Physical examination findings and diagnostic tests 4) Discussion of anatomy, physiology, and pathophysiology 5) Drug study for any medications administered 6) Course of care in the hospital and identified health problems 7) Nursing care plan and evaluation 8) Discharge plan and instructions 9) Consideration of any ethico-legal issues The case study report follows this format to comprehensively document a patient's hospitalization and the resulting nursing care.

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PLT COLLEGE, INC.
Bayombong, Nueva Vizcaya
School of Health Sciences-College of Nursing
CASE STUDY
(Format)
I. PATIENT’S PROFILE
Name: (initial only)
Address:
Birthday:
Age:
Occupation:
Marital Status:
Religion:
Educational Attainment:
Ward:
Room:
Chief Complaint:
Admitting Diagnosis:
Principal Diagnosis:
Date/Time of Admission:
Date/Time of Discharge:
II. NURSING HISTORY
A. History of Past Illness
B. History of Present Illness
C. Socioeconomic History
D. Environmental History
E. Occupational History
F. Family History
G. Lifestyle
H. Recreational Activities
III. PATTERNS OF FUNCTIONING
Before During
Patterns Hospitalization Hospitalization Interpretation/Analysis
1. Health Perception
and Health
Management
2. Nutrition and
Metabolism
3. Elimination
4. Activity and Exercise
5. Cognition and
Perception
6. Sleep and Rest

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7. Self-perception Self-
concept
8. Role and
Relationships
9. Sexuality and
Reproduction
10. Coping and Stress
Tolerance
11. Values and Beliefs
IV. PHYSICAL ASSESSMENT
A. General Survey
B. Vital Signs
Vital Signs Normal Range Findings Interpretation/Analy
sis
Pulse Rate
Respiration
Temperature
Blood Pressure
C. Height and Weight (Compute for Body Mass Index)
D. Cephalocaudal Assessment
Part Normal Findings Findings Interpretation/Analysis
V. DIAGNOSTIC EXAMINATION(S)
Diagnostic Exam Normal Range Findings Interpretation/Analysis
VI. ANATOMY AND PHYSIOLOGY
VII. PATHOPHYSIOLOGY
VIII. DRUG STUDY
Classification:
Brand Name:
Generic Name:
Mode of Indication Contraindication Side Effect Nursing
Action Implication
IX. COURSE IN THE WARD
X. LIST OF IDENTIFIED PROBLEMS (According to priority)

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NURSING CARE PLAN
Assessment Nursing Analysis Goal Nursing Rationale Evaluation
Dx Intervention
Subjective: Efficiency:
Yes___No___
Objective: Why_______
Effectiveness:
Yes___No___
Adequacy:
Yes___No___
Appropriateness:
Yes___No___
XI. DISCHARGE PLANNING
Medication
Exercise/Environment
Treatment
Health Teaching
OPD Appointment
Diet
Spirituality/Sexuality
XII. ETHICO-LEGAL ISSUE(S)