Format for Med-Surgical Case Study (Appendicitis)
A. Introduction:
1. Personal Information;
– Name (pseudonym), age, sex, gender, ethnicity, religion.
– Wt, ht, any chidren
2. Medical & Surgical History.
– Past medical Hx.
– Past Surgical Hx.
– Obstetric hx(female)
B. Present Chief Complaints
– Events leading to complaints
– Explain what interventions (if any) were taken by patient from the time of getting ill leading up to the time of entering casualty.
– What medical management and nursing management were given to the patient in casualty prior to the patient coming up to the ward.
– State briefly how patient presented on the ward
– Assessment of patient on admission
C. Medical /Surgical Management.
– What was the patient diagnosed as?
– Discuss the pathophysiology of the patient’s condition briefly.
– What was the medical (doctor’s) management ordered for this patient.
– What medication was ordered for this patient, list and say how each drug ordered assisted patient to feel better/ improved patients condition.
– What Investigations/diagnostic tests were done? State briefly why you think these tests were done.
– What is/ surgical management performed on this patient.
– Describe briefly procedure and findings from surgical intervention done.
D. Nursing Management
– List the nursing problems identified in this patient
– State the nursing diagnosis formulated to address this problem
– What was your desired outcome for your patient.
– What nursing measures were done to meet your desired outcome/ alleviate this problem.
(PRE-OP preparations, post –op care: IV, drains, tubes etc)
– What are the possible complications the patient face and what interventions were done to prevent them from occurring.
– State what topics will be taught to patient on discharge and discuss each briefly..
Recommendations: Explain what the patient should do in the future to continue recovery/ improve his or her condition..