Case Report

The case report should include:

Brief introduction (one paragraph)
1. Presenting complaint and diagnoses
2. Include pathophysiology of patient’s acute health problem
3. Past medical and health history including medications
4. Family and personal history
5. Impact of acute health problem on the patient, family and significant others
• Include identification of actual and potential healthissues
• Physical and psychological impact on activities of daily living
6. Health assessment

Detail the patient’s care plan including:
7. therapeutic interventions (include pre and post-operative care)
8. medications administered including principles of their action, side effects,dosage, route of
administration,patient response
9. rationale for the planned care and therapeutic interventions
10. how you contributed to the planning and delivery of care for the patient
11. Emergency situations,adverse events,deterioration and how managed

Discharge planning including:
12. Health education provided and how you contributed to the health education of the patient
13.Resources, support services,referrals
14. Discharge location and care person