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. Chart Records
b. Patients Consent

1. Assessment
2. Chart Recording
3. Interview
4. 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
Dearly Mae T. Florentino
Stephen N. Garcia
Dishaun G. Marcos
Daryl Fritz Nasala
Janelle Frances Paris
Sanch Gerald A. Sy

Clinical Instructors

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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
II. Health History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.0
a. Past Health History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.0
b. Present Health History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.0
c. Family History in a Genogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.0
III. Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.0
a. Assessment Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
IV. Anatomy and Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.0
V. Concept Map . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.0
a. Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.0
b. Symptomatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
VI. Nursing Process Record(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.0
VII. Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.0
VIII. Theoretical Base Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.0
IX. 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 and Respiratory Rates and 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.


ANATOMY AND PHYSIOLOGY
The first paragraph will briefly describe why the disease will affect the following organs in the
body and their functions.
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.
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.
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.

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 25mg 1 tab p.r.n.
Brand Name 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

APPENDICES

APPENDIX A
Patients Consent

APPENDIX B
Intake and Output Monitoring Sheet
January 13, 2014
Monday
INTAKE OUTPUT
AM 100 100
PM 100 100
NOC 100 100
TOTAL 300 300


APPENDIX C
Laboratory and Diagnostic Test Results

January 13, 2014
Monday
08:53 AM NAME OF THE TEST
Criterion Normal Value Result Interpretation Significance


January 13, 2014
Monday
08:53 AM NAME OF THE TEST

Reading

Impression


APPENDIX D
Progress Notes
Date Time Assessment Order
Date Time Assessment Doctors Order
January 13, 2014
Monday
08:54 AM FBS 550 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
Temperature Pulse Rate Respiratory Rate Blood Pressure
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
In this section, descriptions of the results from the monitoring will be written
concisely.