discharge summary jagonoy

8/19/2019 Discharge Summary JAGONOY

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FEU – DR. NICANOR REYES MEDICAL FOUNDATIONMEDICAL CENTER

Regalado Avenue, corner Dahlia Street West Fairview, Quezon City 1118Tel !o" #$%&'$1(

DEPARTMENT OF INTERNAL MEDICINE

DISCHARGE SUMMARY

Registration # !"$%Case # !"&'%(Roo) # )'*&D

Na)e Antonio JagonoyAge*Se+ *#+

,or-ing Diagnosis CVA InfarctFina Diagnosis Acute Cere-ral .n/arct, 0e/t Corona Radiata and osterior 0i- o/ .nternal ca2sule 2ro-a-ly S3D,

!.4SS ), 4C3D SR FC .Date o/ A0)ission Dece-er 8, $'1)Do1tors2in2C3arge Dr a-lo+Chua

4IIC Carandang, Marichelle D.CO24IIC Katerina Mae, Fernando F.

Leocadio, Mark Roldan M.Diana Rose, Alcantara R.

De5art)ent .nternal 5edicine

CLINICAL HISTORY

December 8, 2015 Informant: PatientReliability: !"

GENERAL DATA:Antonio Jagonoy, #$years old, %ale, %arried, &elder, Ro%an Catholic, Fili'ino, (orn

on Jan)ary *, +*!+ at )(oso, -egros ccidental 'resently residing at/lk. 0 lot 1*+ area #2/3aint. Michael 3t. /rgy. 4oly 3'irit, 5)e6on City. Ad%itted for the +st ti%e on Dece%(er ,78+! at F9:2-RMF Medical Center.

CIE! C"#$LAINT; &eakness of right )''er and right lo&er e<tre%ities for 0days

I%T"R& "! $RE%ENT ILLNE%%:4istory of 'resent illness started hree days 'rior to ad%ission, the 'atient

e<'erienced s)dden &eakness of right )''er and right lo&er e<tre%ities acco%'anied (ydia'horesis, di66iness non2rotatory and headache descri(ed as ')lsatile, nonradiatinglocated at left occi'ito2'arietal region &ith a 'ain scale of !=+8, relie>ed (y rest. here &ere

no other signs and sy%'to%s s)ch as loss of conscio)sness, sl)rring of s'eech, fe>er, chills,>o%iting. -o %edications taken. -o cons)ltation done.

&o ho)rs 'rior to ad%ission, still &ith the a(o>e sy%'to%s, no& acco%'anied &ith sl)rringof s'eech. his 'ro%'ted cons)lt to o)r instit)tion and &as s)(se?)ently ad%itted.

$A%T #EDICAL I%T"R&:4ad %)%'s, %easles, and chicken'o< d)ring childhood-ot kno&n hy'ertensi>e-ot kno&n dia(etic@2 /ronchial Asth%a@2 Allergies to food and dr)gsAccident;+*B#2 &as hit (y a steel in his chest, no %anage%ent done



-o 're>io)s s)rgery, 'sychiatric diseases or (lood transf)sions

!A#IL& I%T"R&:Mother deceased at age $ d)e to child (irthFather deceased at age B! years old d)e to Myocardial Infarction-o other heredofa%ilial disease s)ch as hy'ertension, dia(etes, asth%a, l)ng, li>er,

kidney and thyroid diseases

$ER%"NAL AND %"CIAL I%T"R&:Patient is c)rrently &orking as a &elder. Married for 7* years. 4e li>es in a ()ngalo&

ty'e, &ell2lit and &ell >entilated &ith his &ife, three grandchildren and sister2in2la&. Patientstarted to s%oke at the age of +# and sto''ed at $8 years old. 4e &as a 0.# 'ack years%oker. 4e slee's for +8 ho)rs fro% '% to #a%. 4e )s)ally eats sh and >egeta(les.Drinks 7 c)'s of coEee a day. 3tared to drink alcohol at the age of +# and sto''ed at the ageof $8. 4e )s)ally cons)%es 720(ottles of (eer, t&ice a &eek. 4e &alks for 78%in)tes in the%orning. 4e is right2handed.

RE'IE( "! %&%TE#%:Con)tit*tional )ym+tom): @2 (ody &eakness @2 fe>er @2 &eight loss%in: @2 itchiness, @2 e<cessi>e s&eating, @2 cyanosis, @2 'allor, @2 a)ndiceea-: @2 di66iness @2 headache, @2 >ertigo,Eye): ./ bl*rrin of i)ion.Left, @2 e<cessi>e lacri%ation @2 'hoto'ho(iaEar): @2 earache, @2 deafness, ./ tinnit*), @2 ear discharge #o*t3 4 T3roat: @2 sore throat, @2 toothache, @2 g)% (leeding, @2 dist)r(ance in tasteNec: @2 %ass, @2 neck >ein engorge%entRe)+iratory: @2 he%o'tysis, @2 diGc)lty of (reathing, @2 ortho'neaCar-ioa)c*lar: @2 'al'itations, @2 synco'eGa)trointe)tinal: @2 loss of a''etite, @2 a(do%inal 'ain, @2 na)sea, @2 >o%iting, @2dys'hagia, @2 diarrhea, @2 consti'ationGenito*rinary: ./ -ic*lty of *rination, @2 )rinary fre?)ency, @2 )rgency, @2he%at)ria. @2 noct)riaE6tremitie): @2 ede%a, @2 s&elling of oints, @2 li%itation of %o>e%ent, @2lesionsNero*): @2 headache, @2 >ertigo, @2 synco'e, @2 n)%(ness, @2 loss of %e%ory, @2 loss of conscio)snessematoloic: @2 'allor, @2 easy (r)isingEn-ocrine: @2 intolerance to heat H cold, @2 'olydi'sia, @2 'oly)ria

PHYSICAL E6AMINATION

General %*rey: Patient is conscio)s, coherent, not in cardiores'iratory distress. Looksa''ro'riate for his age and he is oriented to ti%e 'lace and 'erson &ith the follo&ing >italsigns;/P; +!8=+88 %%4g CR; B0('% RR; +*c'% e%'erat)re; 0#.BC 87 3at; *"

%in: /ro&n in color, has nor%al %o(ility, dry. -ail (eds are 'ink, nail 'lates are s%ooth, nolesion nail folds are nor%al looking.

ea-: 4air is (lack to gray, thick, e>enly distri()ted, nor%oce'halic, sy%%etrical, no %ass,no tenderness, te%'oral arteries are not >isi(le ()t 'al'a(le, &ith strong e?)al ')lsations.

Eye): 9ye(ro&s are (lack, e>enly distri()ted, no erythe%a and no lesions noted 'al'e(ralss)res sy%%etrical eyelashes are thin &ith o)t&ard direction of gro&th, no %atting, noe<o'hthal%os or eno'hthal%os on (oth eyes. Pink 'al'e(ral con)ncti>ae, yello&ish &hitesclerae at the nasal and te%'oral side, no clo)ding of the cornea, irises are dark (ro&n &ithreg)lar conto)r, ')'ils %eas)re 720 %% and e?)ally reacti>e to light.



Ear): 3y%%etrical, y%'anic %e%(ranes &ere not seen d)e to co%'lete (lockage of thickaky %aterial.

No)e: 3y%%etrical, &ith 'atent >esti()les, and %)cosa is 'ink, se't)% at %idline andintact, no congested t)r(inates, no nasal discharge.

#o*t3 an- "ral Caity: Li's are 'ink and %oist ()ccal %)cosa and g)%s are 'inkish ands%ooth. ong)e is slightly de>iated to the right )'on 'rotr)sion. :>)la is at %idline. onsilsnot enlarged.

Nec: 3y%%etrical, soft, s)''le neck, no defor%ities, no 'al'a(le ly%'h nodes. hyroidgland is not 'al'a(le. -o neck >ein engorge%ent. -o carotid (r)it noted.

L*n)7C3e)t: 3kin is (ro&n, no >isi(le %ass, no dilated s)'ercial (lood >essels,sy%%etrical chest e<'ansion, no s)'racla>ic)lar and intercostal retractions noted.

eart: Adyna%ic 'recordi)%, no 'recordial ()lging, a'e< (eat is at the ! th intercostal s'aceleft %idcla>ic)lar line, nor%al rate H reg)lar rhyth%. 37 is lo)der than 3+.

Ab-omen: 3y%%etrical, (ro&n, no lesions, no scars. Flat a(do%en &ith nor%oacti>e (o&elso)nds. -o ()lging anks. -o tenderness )'on s)'ercial and dee' 'al'ation. 3)'ercial(lood >essels are not >isi(le and not 'al'a(le. -o a(nor%al ')lsations, no >isi(le 'eristalsis

E6tremitie): -o gross defor%ities, no ede%a &ith f)ll e?)al ')lses, no cyanosis.

NER"L"GIC E9A#INATI"NCere(r)%; Patient is conscio)s, a&ake, oriented to ti%e 'lace and 'erson, can talks'ontaneo)sly and follo& >er(al co%%ands. C3 score of +! @9$V!M#Cere(ell)%; -o nystag%)s, no intention tre%ors, @2 Ro%(ergs sign, @2 tactile agnosia, canfollo& si%'le instr)ctions and ans&er ?)estions, can do nger2to2nose test

Cranial ner>es;C- I; can s%ell coEeeC- II; o'hthal%osco'ic ndings; @N RR and @N direct and indirect light ree<, AV ratio 7;0C- III, IV, H VI; Intact 9Ms, no 'tosisC- V; @N corneal ree<, (ilateral can clench teeth e?)ally on (oth sides, can disting)ishlight to)ch, &ith 'ain sensation, can o'en and close %o)th &itho)t diGc)ltyC- VII; -o facial asy%%etry closes eyes tightly, can raise eye(ro&, can fro&nC- VIII; @2 laterali6ation in Oe(ers est AC/C in Rinnes estC- IQ and Q; @N s&allo&ing @N gag ree< )>)la at %idlineC- QI; can shr)g (oth sho)lders ()t &ith &eakness on the rightC- QII; ong)e de>iated to the right )'on 'rotr)sion

0=!

1''

1''

(+)

(+)



COURSE IN THE ,ARD

62on adission to .nternal 5edicine Station )7, 2atient has a CS o/ 1) 9:#3)5*;, not in cardiores2iratorydistress, with the /ollowing vital signs" 7 < 1)'+1'', 4R < %(, RR < 1=, Te2 < (*%, >$ sat < =8? 0a-oratory testsdone were C7C , Seru !a, @, Creatinine, ST, C7, F7S, 0i2id 2ro/ile, 1$lead :C, Chest &Ray, 6rinalysiswhich revealed noral W7C 98)(; with 2redoinance o/ neutro2hils 9=(ol+0; and onocytes 9''%'ol+0;,noral seru Sodiu 9!a" 1(8 ol+0;, noral seru @ 9(=' ol+0;, high heoglo-in 91*)g+0;, noralheatocrit 9'#8#0+0; noral 5C3 98*% /l, noral 5C4 9$=*2g;, !oral 5C4C 9(#1 g+0;, noral RDW&C391(1?;,noral RDW&SD 9#1/l;, noral 2latelet count 91=* B1'=+0;, noral 53 988 /l; and noral DW 9=' /l;6rinalysisrevealed yellow, hazy, no -lood and -iliru-in, 6ro-ilinogen o/ 1, no trace o/ Eetone, 2rotein, nitrite,leuEocytes and glucose with a 24 o/ 8', s2eci/ic gravity o/ 1'1', with an occasional e2ithelial cells, urates and-acteria !on&contrast cranial 5R. showed an acute ischeic in/arction, 0e/t corona radiate and 2osterior li- o/ 0e/tinternal ca2sule, chonic sall vessel ischeic changes, nons2eci/ic -looing arti/act with shine&through is seen inthe right /rontal area C7 revealed 8=g+dl !SS 10 at *'cc+hour now was started >n low salt low /at diet 3italsigns were onitored every hour and . .ntaEe and >ut2ut were onitored every shi/t 4es on ASA 8'g+ta- >Da/ter lunch, Atorvastatin #'g+ta-, 1ta- >D4S, Citicholine 1g+ta- 7.D, >e2razole #'g+ta- >D, 0actulose ('cc>D4S hold /or 75G$B+day, aintained 5A o/ 11'&1('4g, elevated head o/ the -ed ('degrees, was re/erred to!euro /or evaluation

>n the $nd hos2ital day, lactulose was increased to $'cc 7.D and was hold /or when -owel oveent isgreater than twice a day .3 /luid was decreased to *'cc 2er hour and 2rogression o/ neurologic de/icit was watchedout /or 7actidol gargle was started 1)l T.D /or *' seconds and was re/erred accordingly !a, @, Ca and STwere /ollowed u2

>n the (rd hos2ital day to consue i3F then shi/t to he2locE 4e can sit and drag /eet and he was re/erredto reha-

>n the #th hos2ital day, reha-ilitation was /acilitated and the 2atient was given DulcolaB su22ository /or -owel oveent

LA7ORATORY E6AMINATIONS

+7=*=+!

TE%T RE%LT NIT RE! RANGE #ET"Dl)cose @F/3 !.! %%ol=L $.++2!.!*

%%ol=Lhe<okinase

LIPID PRFIL9 otalcholesterol

!.#7 %%ol=L 8.882!.78%%ol=L

C4P2PD

riglyceride +.$ %%ol=L 8.827.7#%%ol=L

P2PAP

4DL +.00 %%ol=L Male; +.$!%%ol=LFe%ale;+.#%%ol=L

4o%ogeno)sen6y%aticcoloi%eter

LDL 0.#7 %%ol=L 8.8827.!*%%ol=L

VLDL 8.#B %%ol=L 8.8828.0$

0=!0=!



%%ol=L

PHYSICAL E6AMINATION UPON DISCHARGE

General %*rey: Patient is conscio)s, coherent, not in cardiores'iratory distress. Looksa''ro'riate for his age and he is oriented to ti%e 'lace and 'erson &ith the follo&ing >italsigns;/P;+78=*8 CR; B! RR; +* e%'erat)re; 0B.7 87 3at; *#"

%in: /ro&n in color, has nor%al %o(ility, dry. -ail (eds are 'ink, nail 'lates are s%ooth, nolesion nail folds are nor%al looking.

ea-: 4air is (lack to gray, thick, e>enly distri()ted, nor%oce'halic, sy%%etrical, no %ass,no tenderness, te%'oral arteries are not >isi(le ()t 'al'a(le, &ith strong e?)al ')lsations.

Eye): 9ye(ro&s are (lack, e>enly distri()ted, no erythe%a and no lesions noted 'al'e(ralss)res sy%%etrical eyelashes are thin &ith o)t&ard direction of gro&th, no %atting, noe<o'hthal%os or eno'hthal%os on (oth eyes. Pink 'al'e(ral con)ncti>ae, yello&ish &hitesclerae at the nasal and te%'oral side, no clo)ding of the cornea, irises are dark (ro&n &ithreg)lar conto)r, ')'ils %eas)re 720 %% and e?)ally reacti>e to light.

Ear): 3y%%etrical, y%'anic %e%(ranes &ere not seen d)e to co%'lete (lockage of thickaky %aterial.

No)e: 3y%%etrical, &ith 'atent >esti()les, and %)cosa is 'ink, se't)% at %idline andintact, no congested t)r(inates, no nasal discharge.

#o*t3 an- "ral Caity: Li's are 'ink and %oist ()ccal %)cosa and g)%s are 'inkish ands%ooth. ong)e is slightly de>iated to the right )'on 'rotr)sion. :>)la is at %idline. onsilsnot enlarged.

Nec: 3y%%etrical, soft, s)''le neck, no defor%ities, no 'al'a(le ly%'h nodes. hyroidgland is not 'al'a(le. -o neck >ein engorge%ent. -o carotid (r)it noted.

L*n)7C3e)t: 3kin is (ro&n, no >isi(le %ass, no dilated s)'ercial (lood >essels,sy%%etrical chest e<'ansion, no s)'racla>ic)lar and intercostal retractions noted.

eart: Adyna%ic 'recordi)%, no 'recordial ()lging, a'e< (eat is at the ! th intercostal s'aceleft %idcla>ic)lar line, nor%al rate H reg)lar rhyth%. 37 is lo)der than 3+.

Ab-omen: 3y%%etrical, (ro&n, no lesions, no scars. Flat a(do%en &ith nor%oacti>e (o&elso)nds. -o ()lging anks. -o tenderness )'on s)'ercial and dee' 'al'ation. 3)'ercial(lood >essels are not >isi(le and not 'al'a(le. -o a(nor%al ')lsations, no >isi(le 'eristalsis

E6tremitie): -o gross defor%ities, no ede%a &ith f)ll e?)al ')lses, no cyanosis.

NER"L"GIC E9A#INATI"NCere(r)%; Patient is conscio)s, a&ake, oriented to ti%e 'lace and 'erson, can talks'ontaneo)sly and follo& >er(al co%%ands. C3 score of +! @9$V!M#



Cere(ell)%; -o nystag%)s, no intention tre%ors, @2 Ro%(ergs sign, @2 tactile agnosia, canfollo& si%'le instr)ctions and ans&er ?)estions, can do nger2to2nose test

Cranial ner>es;C- I; can s%ell coEeeC- II; o'hthal%osco'ic ndings; @N RR and @N direct and indirect light ree<, AV ratio 7;0

C- III, IV, H VI; Intact 9Ms, no 'tosisC- V; @N corneal ree<, (ilateral can clench teeth e?)ally on (oth sides, can disting)ishlight to)ch, &ith 'ain sensation, can o'en and close %o)th &itho)t diGc)ltyC- VII; -o facial asy%%etry closes eyes tightly, can raise eye(ro&, can fro&nC- VIII; @2 laterali6ation in Oe(ers est AC/C in Rinnes estC- IQ and Q; @N s&allo&ing @N gag ree< )>)la at %idlineC- QI; can shr)g (oth sho)lders ()t &ith &eakness on the rightC- QII; ong)e de>iated to the right )'on 'rotr)sion

8'

8'

#+)

)+)

discharge summary jagonoy

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