506d final history

8/19/2019 506D Final History

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FEU – DR. NICANOR REYES MEDICAL FOUNDATION MEDICAL CENTERRegalado Avenue, corner Dahlia Street West Fairview, Quezon City 1118

Tel !o" #$%&'$1(

DEPARTMENT OF INTERNAL MEDICINE

CLINICAL HISTORY December 17, 2015 I!"rm#$%

Re&'#b'&'$(% 8)*

)ENERAL DATA%Forsales, Adol+o !uez, -$ years old, .ale, single, Fili/ino, Christian, 0orn on

uly 1%, 12)(, /resently residing on 3isayas St, 4atasan 5ills, Quezon City, ad.itted+or the $nd ti.e to F67& !RF edical Center on Dece.0er 1, $'1)

CHIEF COMPLAINT" loss o+ consciousness

HISTORY OF PRESENT ILLNESS%

The history /resent illness started si9 hours /rior to ad.ission when /atientwas +ound lying on the :oor, slightly conscious and with inco./rehensi0le words andgroaning with associated right&sided 0ody wea;ness !o associated signs andsy./to.s such as nausea or vo.iting <atient was then rushed to the 6.ergencyDe/art.ent o+ F67&!RF edicine where he was su0se=uently ad.itted

PAST MEDICAL HISTORY%$'1$, yocardial >n+arction, ad.itted in the >ntensive Care 7nit o+ F67&!RFedicine$'1$, Cere0rovascular Accident$'1$, Angiogra. done at <hili//ine 5eart Center, advised angiogra/hy 0ut /atientdeclined due to ?nancial constraint122), Diagnosed with 5y/ertension, /atient was /rescri0ed with anti&hy/ertensive

drugs 0ut he was not co./liant due to /atient@s /re+erence!o 5istory o+ Dia0etes, Thyroid disease, Asth.a, nor Allergy

F#m'&( H'*$"r(%Father" Diseased, due to a cere0rovascular accident, and was ;nown hy/ertensiveother" Diseased, died due to /neu.onia<atient is the )th a.ong - children Sister was deceased due to 0reast cancer<atient has # children, all a//arently well

Per*"#& #+ S"c'#& H'*$"r(%<atient is a retired /rivate e./loyee, lives in a 0ungalow ty/e house with electriclighting Water su//ly co.es +ro. aynilad Drin;ing water is /uri?ed <atientusually slee/s +or (&) hours 4iodegrada0le gar0age is collected twice a wee; and

non&0iodegrada0le gar0age is collected once a wee; <atient was a 1$&/ac; years.o;er and a /revious alcoholic 0everage drin;er <atient has no +or. o+ e9ercise

REIE- OF SYSTEMS%C"*$'$$'"#& *(m/$"m*% B& +ever, B& chills,S'% B& itchiness, B& e9cessive sweating, B& cyanosis, B& /allor, B& aundice, B&erythe.a, B& dry s;inHe#+% B& dizziness B& headache, B& vertigoE(e*% B& 0lurring o+ vision B& e9cessive lacri.ation B& /hoto/ho0ia



E#r*% B& earache, B& dea+ness, B& tinnitus, B& ear discharge, B& ear itchinessM"$ Tr"#$% B& dry li/s and tounge, B& sore throat, B& toothache, B& gu.0leeding, B& distur0ance in tasteNec% B& .ass, B& nec; vein engorge.entRe*/'r#$"r(% B& /lueritic chest /ain, B& coughC#r+'"3#*c&#r% B& /al/itations, B& synco/e

)#*$r"'$e*$'#&% B& loss o+ a//etite, B& a0do.inal /ain, B& nausea, B& vo.iting,)e'$"r'#r(% B& dysuria, B& urinary +re=uency, B& urgency, B& he.aturia B&nocturiaE4$rem'$'e*% B& swelling o+ ointsNer3"*% B& headache, B& vertigo, B& synco/e, B& nu.0ness, BE loss o+ consciousnessHem#$"&"'c% B& /allor, B& easy 0ruisingE+"cr'e% B& intolerance to heat cold, B& /olydi/sia, B& /olyuria

PHYSICAL E6AMINATION

)eer#& *r3e(% unconscious, a+e0rile, not in cardiores/iratory distress with no

signs o+ dehydration

4<" $$'G1#' CR" 1$' 0/. RR" Assisted Te./" (-)HCI$ Saturation" 2%*

HEENT% /in; /al/e0ral conunctivae, white sclera, /in; nasal tur0inates, .oist li/sand 0uccal .ucosa /in; /haryngeal wall,c% Su//le, no /al/a0le ly./h nodes and .assesCe*$L*% with su/raclavicular retractions and 0i0asal crac;lesHe#r$% Adyna.ic /recordiu., tachycardic at 1$'0/., with regular rhyth., no.ur.ur)IT% glo0ular, distended, no /al/a0le .ass$'e*% !o gross de+or.ities, +ull and e=aul /ulses, ca/illary re?ll ti.e J$ seconds

S'% !o active der.atoses

NEUROLO)IC E6AMINATION%

Cerebrm% KCS o+ ( B61311, unconsciousCerebe&&m% !o nystag.us, gait not assessedCr#'#& Ner3e*%

I% not assessedII% $&(.. /u/ils e=ually reactive to lightIII, I #+ I% >ntact e9traocular .uscles% with corneal re:e9II% !o +acial assy.etryIII% can not 0e assessedI6 #+ 6% can not 0e assessed6I% not assessed6II% not assessed

MOTOR SENSORY% not assessed DTR% notassessed1G) 1G)1G) 1G)



Me'e#& *'*% !o nuchal rigidity, B& Lernig, B& 4rudzins;iP#$"&"'c re8e4e*% BE 4a0ins;i

NEUROLO)IC E6AMINATION

Cere0ru." <atient is conscious, awa;e, oriented to ti.e /lace and /erson, can tal;s/ontaneously and +ollow ver0al co..ands KCS score o+ 1) B6#3)-Cere0ellu." !o nystag.us, no intention tre.ors, B& Ro.0erg@s sign, B& tactileagnosia, can +ollow si./le instructions and answer =uestions, can do ?nger&to&nosetest

Cranial nerves"C! >" can s.ell coMeeC! >>" o/hthal.osco/ic ?ndings" BE RIR and BE direct and indirect light re:e9, A3ratio $"(C! >>>, >3, 3>" >ntact 6Is, no /tosisC! 3" BE corneal re:e9, 0ilateral can clench teeth e=ually on 0oth sides, can

distinguish light touch, with /ain sensation, can o/en and close .outh withoutdiNcultyC! 3>>" !o +acial asy..etry closes eyes tightly, can raise eye0row, can +rownC! 3>>>" B& lateralization in We0er@s Test ACO4C in Rinne@s TestC! >P and P" BE swallowing BE gag re:e9 uvula at .idlineC! P>" can shrug 0oth shoulders 0ut with wea;ness on the rightC! P>>" Tongue deviated to the right u/on /rotrusion

A**e**me$%Acute ische.ic in+arction, e+t Corona Radiata and <osterior i.0 o+ >nternal

Ca/sule

P&# O A+m'**'"%6levate head o+ 0ed (' degrees, re+er +or neuro evaluation, co./lete neuro <6and 5istory

D'e$% low salt, low +at with SA<

IF" <!SS 9 -'ccGhr

D'#"*$'c*% C4C, Sodiu., <otassiu., Creatinine, SK<T, C4K, F4S, i/id <ro?le, 1$lead 6CK, Chest Pray Bhigh A< sitting, urinalysis

(G) 1'

1''

1''

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(G) )G)



Me+'c#$'"*%ASA 8' .gGta0, 1 ta0 ID a+ter lunchAtorvastatin #' .gGta0, 1 ta0 ID5SCiticoline 1gGta0, 1 ta0 4>DI.e/razole #'.gGta0, 1 ta0 ID (' .in 0e+ore 0rea;+ast

actulose (' cc ID5S, hold +or 4 OG $9Gday

HISTORY TA9EN :Y% >>C" Carandang, arichelle DCo&>>C" Alcantara, Diana Rose R

Fernando, Laterina ae Feocadio, ar; Roldan,

506d final history

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