This document is a comprehensive case study template used for collecting detailed demographic and medical data of patients, including personal history, family health status, and various examination findings. It outlines sections for recording vital signs, physical examinations across different body systems, and specific investigations along with nursing management details. The structure aims to facilitate a systematic approach to patient assessment and care planning.

1. Case study
Demographic data:Name:Age:Gender:I.P. D No.:Ward:Address:Education:Occupation:Marital status :Religion:Date of admission:Name of the surgery:Type of anesthesia:Allergic to:Date of discharge:Brief socioeconomic history






Family history:Health status of family members:Total income:Dietary habits:Housing condition:Inter personal relationship:-
Personal history
 Personal hygiene: History of allergy: History of past illness:-

2.  History of present illness:Vital signs
Temp:
pulse:
Head to toe examination
General appearance




Body type:Posture:Gait:Activity:-
Vital signs




Temperature:Pulse:Respiration:Blood pressure:-
Height and weight
Integument
Skin:
 Colour: Moisture: Temperature: Texture: Turgor: Vascularity: Lesions:Hair and scalp:
 Distribution: Colour: Appearance: Scalp: Hair follicles:Nails:
 Color: Thickness: Shape:Head And Neck
resp:
B.P:

3. Head:
 Position:Eyes:










Position and alignment:Eyebrows:Eyelids:Lacrimal ducts:Conjunctiva:Sclera:Cornea:Pupil:Lens:Visual acuity:-
Ears:
 Auricles: Ear drum: Hearing acquity:Nose:





External nares:Mucosa:Discharge:Nasal septum:Sinuses:-
Mouth and pharynx:







Lips:Mucosa:Gums:Teeth:Tongue:Palate:Pharynx:-
Neck:
 Neck muscles: Lymph nodes:-

4.  Thyroid gland: Trachea:Thorax And Lungs
Posterior thorax:







Contour:Intercostal spaces:Rhythm of breathing:Thoracic muscles:Fremitus:Percussion:Auscultation:-
Anterior thorax:




Thoracic muscles:Fremitus:Percussion:Auscultation:-
Lateral thorax:
 Percussion:Heart




Inspection:Palpation:Auscultation:Heart rate:-
Breast
 Inspection: Nipple: Palpation:Abdomen




Inspection:Palpation:Percussion:Auscultation:-
Genitalia (Female)

5. 



Labia majora:Labia minora:Urethral orifice:Vaginal orifice:-
Genitalia (Male)
 Penis: Scrotum: Inguinal ring and canal:Rectum And Anus
 Inspection: Digital palpation:Musculoskeletal System




Inspection:Palpation:Range of motion:Muscle tone and strength:-
Neurological System
 Level of consciousness: Behavior: Cranial nerve function:Reflexes:
 Biceps: Triceps: Patellar: Achilles: Plantar: Gluteal: Abdominal:Assessment
Subjective data:Objective data:-
Investigations

6. Patient’s value
S.No. Name of investigation
Normal value
Doctor’s order
Doctor’s Order
S.No.
Purpose
Case in detail








Introduction
Definition
Etiology
Pathophysiology
Clinical manifestations
Diagnostic findings
Surgical management
Nursing management
Nursing care plan :Assessment
Subjective data
Objective data
Nursing
diagnosis
Goal
Planning
Rationale
Implementation
Evaluation

7. Health education:S.No.
Date
Topic
Nurse’s record :Date
Recording
Signature