III.

Physical Examination

Emergency Assessment

I.

Primary Assessment Airway Open airway Able to speak (-) foreign objects or anything that obstructs the airway

Breathing (+) equal breath sounds of both lungs 1 bp! and O"ygen saturation of (-) use of accessory !uscles #

$irculation (-) bleeding (+) war! skin

%isability Alert &$'(1)* +,*-)*./ (+) 0+112A

II.

Secondary Assessment History

'igns and 'y!pto!s 3 2eft 'ided 4eakness and 'lurred 'peech Allergies 3 5o known allergies to food and !edications .edication 3 0atient taking !aintenance drug but stopped it for 6 !onths 7A!lodipine* 'i!8astatin and -ita!in B-co!ple"9 0re8ious .edical :istory 3 ;ear 6<<) his pre8ious stroke e8ent and ad!itted at the =ondo &eneral :ospital 2ast oral intake 3 2ate afternoon around ,>?<0. before they went to +1 around 6>?< 0. on the ne"t day@ +8ents leading up to the e!ergency 3 patient unable to !o8e his left part of body

Vital signs: B0> 1,<A < !!A:g 01> B, bp! 11 > 1 cp! =e!p> ?C@? D$

III.

Physical Assessment 'yste! Eindings Bed-ridden due to the patient is e"periencing a left sided weakness with a !otor strength of ?A) on his both left upper and lower e"tre!ities@ Analysis =rans!ission of the !otor neurons had decreased slightly on his left upper and lower e"tre!ities due to the right brain da!age@ Fnterpretation :istory showed that the patient was already had a pre8ious stroke last 6<<) and its recurrence !ay be due to the progression of his :ypertension and unchanged diet@

.usculoskeletal 'yste!

5er8ous 'yste!

0atient showed a right facial weakness by way of s!iling and he speaks in a slightly slurred !anner@ :is tongue protrudes to the left and he also e"hibits a decreased sensation on his left e"tre!ities@

=rans!ission of the sensory and !otor neurons had decreased on tongue* facial and e"tre!ities !uscle@ Ft indicates da!age to his right part of brain@

:istory showed that the patient suffered the sa!e thing pre8iously and its recurrence probably due to the progression of his :ypertension and unchanged diet@

$ardio8ascular A $irculatory 'yste!

=he patient ha8e a blood pressure of 1C<A1<< !!A:g

=he endotheliu! of the artery beca!e narrowed and the heart pu!ped blood throughout the body with a higher pressure@

:istory showed that his Blood 0ressure progressions are due to his nonco!pliance on !aintenance-!eds and unchanged lifestyle@