Case study scenario# 2
LEPHON
CaseStudyExample.docxCase Scenario/Study
Student Name:
Submission Date:
Total time for case study completion:
Case Study:
Patient Initials, Age, Gender
Subjective information from patient (History of Present Illness/Symptoms)
- Current Medications
- Medical History – Medical Problems
Objective findings from physical examination
- Vital Signs, Weight, Height, BMI
- Focused examination findings based on diagnoses being addressed
Assessment
- ICD-10 Diagnosis (include ICD-10 code)
- Nursing Diagnoses (i.e. 2021 Nursing Diagnosis Guide | Examples & Types (nurse.org)
Plan
- Care Plan based on diagnosis
- Include specific nursing care planning for patient to include
o Potential issues with achieving quality, comprehensive care
o Information on best practice care considerations
o Care outcomes from current treatment
o Possible side effects of medications or treatments
o Patient education planning/instructions
o Care outcomes
o Plans for follow-up to review response to treatment
References:
