Case Presentation Output Checklist

A. Cover Page
B. Table of Contents
C. Introduction
a. P1 Write a brief description of the disease state what is wrong with this disease.
b. P2 Write a brief description of
c. P3 Write a brief description of the possible contributing and precipitating factors to
the disease and the individuals who are susceptible in acquiring the disease.
d. P4 Write a brief description of the prevalence of the disease in the region, the
country, and the world.
e. P5 write a brief description of the treatments including medications to and for the
disease, available in the country and in the United States.
D. Health History
a. Past Health History Describe what had happened to the patient, including all the
possible events that could have contributed to the development of the patients
disease. Include the environment, the activities, food, attitude, lifestyle, exposures,
treatments, previous illnesses and hospitalizations and many more.
b. Present Health History Describe what had happened to the patient the moment the
signs and symptoms occurred prior to his latest admission up to the point where the
first day of student nurses duty occurred.
c. Family History Write an introduction, show the diagram, and give a brief
explanation or observation of the diagram.
E. Assessment
a. Assessment Diagram
i. Vital Information concisely write down all the vital information related to the
patients disease, including the age, gender, hometown, medical diagnoses, and the
like
ii. Developmental Aspect
iii. Socio-cultural Aspect
iv. Psychological Aspect
v. Physiological Aspect
1. Cerebral and Peripheral Innervation
2. Integumentary System
3. Oxygenation
4. Circulation
5. Hematological Division
6. Immunological Division
7. Digestive and Bowel Elimination
8. Metabolism
9. Reproductive System
10. Urinary Elimination
11. Musculoskeletal System
b. Diagnostic and Laboratory Tests place all the diagnostic tests in tabular form with a
brief description of the observations of the results.
F. Anatomy and Physiology
a. P1 State all the possible and actual parts of the body affected by the disease.
b. P2 and the following Ps Concisely explain all the important functions of the organs
that are possible and actually affected by the disease.
G. Concept Map

a. Pathophysiology
b. Symptomatology
H. Nursing Process Records
I. Medications
J. Theoretical Knowledge Base
K. Appendices
a. Progress Notes
b. Patients Consent
c. TPRBP Sheet
d. I&O
e.

1.
2.
3.
4.

Assessment
Chart Recording
Interview
Oversee

MEDICAL DIAGNOSIS

A paper submitted to the

School of Nursing, Mountain View College

In Partial Fulfillment of the course

Nursing Care Management 107 B: RLE

Ven Clyde L. Abesta

Methoshelah Aguda*
Ciara Beth B. Bergado
Dearly Mae T. Florentino
Stephen N. Garcia
Dishaun G. Marcos
Daryl Fritz Nasala
Janelle Frances Paris*
Dece Dawn Z. Samillano
Sanch Gerald A. Sy

Clinical Instructors, RN, MN

Clinical Instructors, RN, MN
Clinical Instructors, RN, MN
January 2014

TABLE OF CONTENTS
I.

About The Medical Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0
a. Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
b. Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
c. Contributing and Precipitating Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
d. Treatments and Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
e. Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

II.

0
Health History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
a. Past Health History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
b. Present Health History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
c. Family History in a Genogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

III.

0
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
a. Assessment Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

IV.

0
Anatomy and Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

V.

0
Concept Map . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
a. Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
b. Symptomatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

VI.

0
Nursing Process Record(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

VII.

0
Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

VIII.

0
Theoretical Base Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0

IX.

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

X.

0
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
a. Patients Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
b. Intake and Output Monitoring Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
c. Laboratory and Diagnostic Test Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
d. Progress Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
e. Temperature, Pulse/Respiratory Rates & Blood Pressure Monitoring Sheet . . . . .
0

ABOUT THE MEDICAL DISEASE

Definition. Briefly write what is wrong with the patient with this disease.
Signs and Symptoms. Briefly enumerate the possible signs and symptoms associated
with the medical disease of the patient.
Contributing and Precipitating Factors. Briefly enumerate the possible contributing
and precipitating factors to the development and progression of the disease of the patient.
Treatments. Briefly state the currently available treatments for the medical disease,
either or both from the country and abroad.
Prevalence. Briefly describe the prevalence of the disease today in the region, country,
and worldwide.

HEALTH HISTORY
Past Health History. Write everything that relates to the development of the patients
disease even from the experiences from his childhood. Include all the medications taken, the
activities done, the experiences, exposures, the environment, hospitalizations, check-ups,
treatments and the like.
Present Health History. Write everything that had happened prior to the current hospital
admission. Describe what happened to the patient days, hours or minutes prior to current
admission and include the treatments done or the reactions that occurred. Also include the events
that occurred since the day of admission to the day prior to the first day of the student nurses
designation to the patient.
Family History. Write a short description of the genogram that will be shown following
this paragraph. Conclude with the most number of disease incidences in the family genogram and
the least.

Insert Genogram Here

Legend:
Fig. 1 The patients family history of diseases as shown in a genogram.

ASSESSMENT
Place your assessment diagram here.

ANATOMY AND PHYSIOLOGY

The first paragraph will briefly describe why the disease will affect the following organs
in the body and their functions.
You can also place a second paragraph here with whatever you want to say about the
anatomy and physiology of the disease.
The Brain. After the first two to three words of the paragraph, the functions of the organ
will follow in relation to the medical disease most likely giving the explanations for the
occurrence of the signs and symptoms.

Insert Image Here

Fig. 2 The Brain and Its Parts

The Lungs. After the first two to three words of the paragraph, the functions of the organ
will follow in relation to the medical disease most likely giving the explanations for the
occurrence of the signs and symptoms.

Insert Image Here

Fig. 2 The Lungs and Its Parts

The Stomach. After the first two to three words of the paragraph, the functions of the
organ will follow in relation to the medical disease most likely giving the explanations for the
occurrence of the signs and symptoms.

Insert Image Here

Fig. 2 The Brain and Its Parts

CONCEPT MAP
Place vertical concept map here. Use software and export to .jpg format.

Contributing Factors. Write down every event in the concept map and give a
corresponding supporting statement. Make sure to include the primary and secondary sources.
Precipitating Factors. Write down every event in the concept map and give a
corresponding supporting statement. Make sure to include the primary and secondary sources.
Disease Progression. Write down every event in the concept map and give a
corresponding supporting statement. Make sure to include the primary and secondary sources.
Signs and Symptoms. Write down every event in the concept map and give a
corresponding supporting statement. Make sure to include the primary and secondary sources.

NURSING PROCESS RECORD

Nursing Diagnosis, NANDA Definition

MEDICATIONS
Benadryl
Brand Name

25mg 1 tab p.r.n.

Frequency and Dosage

Diphenhydramine
Generic Name
An antihistamine used to treat Mr. Patients allergic reactions to chicken and egg plant.
Indication
Side effects include sedation, tiredness, sleepiness, dizziness, disturbed coordination, drying and
thickening of oral and other respiratory secretions, and stomach distress; low blood pressure,
palpitations, increased heart rate, confusion, nervousness, irritability, blurred vision, double vision,
tremor, loss of appetite, nausea.
Side Effects

THEORETICAL KNOWLEDGE BASE

REFERENCES

APPENDICES

APPENDIX A
Patients Consent

APPENDIX B
Intake and Output Monitoring Sheet
January 13, 2014
Monday
AM
PM
NOC
TOTAL

INTAKE

OUTPUT

100
100
100
300

100
100
100
300

APPENDIX C
Laboratory and Diagnostic Test Results

January 13, 2014

Monday
Criterion

January 13, 2014

Monday
Reading
Impression

08:53 AM
Normal Value

08:53 AM

NAME OF THE TEST

Result

Interpretation

NAME OF THE TEST

Significance

APPENDIX D
Progress Notes
Date Time Assessment Order
Date
January 13, 2014
Monday

Time
08:54 AM

Assessment
FBS 550

Doctors Order
Do something.

09:27 PM

FBS 240

Just do something.

APPENDIX E
Temperature, Pulse and Respiratory Rates and Blood Pressure Monitoring Sheet
Date
January 13, 2014
Monday
12:00 MN
01:00 AM
02:00 AM
03:00 AM
04:00 AM
05:00 AM
06:00 AM
07:00 AM
08:00 AM
09:00 AM
10:00 AM
11:00 AM
12:00 NN
01:00 PM
02:00 PM
03:00 PM
04:00 PM
05:00 PM
06:00 PM
07:00 PM
08:00 PM
09:00 PM
10:00 PM
11:00 PM
Monitoring at
hourly rate

Temperature

Pulse Rate

Respiratory Rate

Blood Pressure

In this section, descriptions of the results from the monitoring will be written
concisely.