Patient’s Profile

Name: Patient PAT

Age: 58 years Old
Sex: Male
Height: 162 cm
Weight: 60 kg
BMI: 22.9 kg/m^2
Date of Birth: March 27, 1965
Religion: Methodist
Civil Status: Married
Educational Attainment: High School Graduate
Address: Brgy. Villamor, Cabarroguis Quirino
Occupation: Tricycle Driver
Date Admitted: March 28, 2023
Time Admitted: 9:48 AM
Chief Complaint: Slurred Speech & sided body weakness (Right Paraplegia)
Admitting Diagnosis: Cerebrovascular disease, Infarct vs. Bleed
Final Diagnosis: Cerebrovascular disease Infarct

PATIENT’S MEDICAL HISTORY

PRESENT MEDICAL HISTORY
October 20 ,2021 9:48 in the morning patient is admitted at Quirino Provincial Medical
Center and diagnosed with Acute CVA Infarct Right MCA and October 25, 2021 11:00 in
the morning patient is admitted again and diagnose with Hypertension.
March 25, 2023 The patient claimed that he gets up early in the morning to gather and
cut firewood to be used in his upcoming birthday, while cutting some wood he suddenly
felt weak and as like he was struggling to breath and around 11:30 am he stopped
cutting wood. He tried to cut some wood again after taking an almost two-hour break,
but his son-in-law insisted on continuing what he was doing.
March 27 ,2023 During his birthday party, he drinks alcohol beverages; he does not
smoke, but his son-in-law smokes while they are drinking; his daughter tried to stop him
from drinking because she knew it could trigger his condition, but he did not listen and
continued to drink.
March 28,2023, Since his current job is driving a tricycle, the patient got up early in the
morning but claimed that he doesn't feel well and occasionally feels dizzy and
headache. Despite of his condition he went out to find some passengers. While driving,
he suddenly felt his left arm become weak as well as his left feet and when he tried to
shout for help he struggled to speak clearly as a result he lost control and fell from the
tricycle.
When a couple witnessed what had happened to him, they rushed to help him. They
tried to communicate with him, but they couldn't understand what he was saying, so
they brought him to the nearest hospital, which is at Quirino Provincial Medical Center.
Patient arrived at the hospital conscious, coherent but slurred speech and with a GCS
of 13 and vital signs as follow:
Blood Pressure: 130/100
Respiratory rate: 24
Pulse rate: 107
Temperature : 36.5
Spo2: 98%

PAST MEDICAL HISTORY

1975, patient stated that he was 10 years old when he was bitten by a dog on his right
leg, but he did not seek medical attention and instead was sent to his neighbors for
traditional "tandok". The patient stated that he was 10 years old when he was admitted
to the hospital for the first time and given an asthma diagnosis, and that as he grew into
a fine young man, his asthma would occasionally attack him. He utilized a metered dose
inhaler for his treatment if his asthma would attack. The patient also mentioned that he
received all of his immunizations. He completed his Covid-19 vaccines astrazenica as
well as his booster.

SOCIAL/PSYCHOLOGICAL HISTORY

Patient works as a mechanic and has driven jeepneys in Manila for almost ten years.
He smoked for almost 20 years and only recently quit in 2018. He also drank frequently
in his younger days and now only drinks frequently at the age of 40. After his first
admission, he stopped drinking, but after his recovery, he occasionally drinks again or
when his son-in-law invites him. During the first two months after discharge on his first
admission , he continue his activity of daily living like being a tricycle driver.
 FAMILY HISTORY
GRANDFATHER

&

GRANDMOTHER

S1 S2 S3

+HTN +DM
+HTN -+HTN
+HTN
+DM -DM +DM +ASTHMA

-ASTHMA -ASTHMA -ASTHMA

-CVA -CVA -CVA
+DM
+HTN

+DM
+HTN
GRANDFATHER

&
+DM
GRANDMOTHER
+HTN
+CVA
+ASTHMA

LEGEND:
S1 S2 S3 S4 MOTHER SIDE
+HTN +HTN +HTN +HTN +HTN FATHER SIDE
+DM +DM +DM +DM
MALE
-ASTHMA -ASTHMA -ASTHMA -ASTHMA
FEMALE
-CVA -CVA -CVA -CVA
PATIENT
4
PHYSICAL ASSESMENT

General survey : Patient PAT is in semi-fowler's position, has a PNSS 1L X 18 hr IV line in

his left arm's dorsal metacarpal vein, is dressed in loose black shirts, and is wearing a
diaper. The patient is consciuos and coherent. Patient has left paraplegia and slight
slurred speech. He is aware of the place, the time, and the date.
Date of Assesment : April 1,2023
Time of Assessment: 1:00 am
Day of Confinement: 4 days
BMI: BMI: 22.9 kg/m^2 (normal)
Height: 162 cm
Weight: 60 kg (132.27 lbs)
Vital Signs taken as follow;
Blood Pressure: 130/100 mmHg
Heart Rate: 67 bpm
Respiratory Rate: 24 cpm
Temperature: 36.5 C
Oxygen Saturation: 98%
Glasgow coma scale:
REVIEW OF SYSTEMS
SYSTEMS SYMPTOMS
Integumentary System “May kaunting pasa at gasgas ako dito sa
may kaliwang braso ko pati na rin sa
magkabilaang paa ko “

Nervous System
“Di ako makatulog ng maayos dahil
masyadong maingay yang pasyente na
katabi ko”
Muscular System “Di ko pa rin maigalaw yung kaliwang
braso at paa ko
Circulatory System No significant findings.
Respiratory System No significant findings.
Digestive system No significant findings.
Excretory System No significant findings.

CRANIAL NERVES ASSESSMENT

CN 1 Olfactory Patency is good, air is felt being expelled from opposite nares, the look is
symmetrical, and the odor presented can be identified (cotton balls with
alcohol); no lesions or tenderness
CN2 Optic Clouding vision due to cataract
CN3,4, Oculomotor, Trochlear, Can blink symmetrically and at the same rate, as well as move the eye
6 Abducens smoothly, consistently, and with strength, Pupils converge and constrict as
object moves in toward the nose and pupil responses are uniform (PERRLA)

CN 5 Trigeminal Eyelids blink bilaterally and can identifies light touch and sharp sensations to
forehead, cheeks and chin
CN7 Facial Smiles, frown, show teeth,blows out cheek ,raises eyebrow and close eyes
tightly as instructed Asymmetrical movements on one side of face (left)

CN 8 Vestibulocochlear Able to hear whispered words from 1-2 feet. Unable to hear watch tick from
left ear
CN 9 Glossopharyngeal Identifies taste (salt), weak swallowing
CN 10 Vagus Bilateral, symmetrical rise of soft palate and uvula
CN 11 Spinal accessory Assymetrical, weak contraction of trapezius muscle
CN 12 Hypoglossal Symmetrical tongue with smooth outward movement and bilateral strength

HEAD TO TOE ASSESSMENT

Organ/ Technique Normal Findings Actual Findings Interpretation
System

Scalp Inspection Symmetry  Symmetrical  Symmetrical  Normal

Palpation Texture  Smooth, firm  Few dry flakes are  four days
seen without a
bath
 (-) lesion,  (-) lesion, tenderness,  Normal
tenderness, masses masses

Head  (-) lesion  (-) lesion  Normal

(Facial Inspection
features)
 (-) facial drooping  (+) slight facial  Due to
 drooping (left side) muscle
weaknesse
s (left sided
paraplegia)
 (+) Moist skin  (+) Moist skin  Normal

 (-) pigmentation  (+) pigmentation  Due to

(slight freckles) aging
 (-) rashes  (-) rashes  Normal
Assess motor  Smiles, frown, show  Smiles, frown, show
function teeth,blows out  Normal
teeth,blows out cheek
cheek ,raises ,raises eyebrow and
eyebrow and close close eyes tightly as
eyes tightly as instructed
instructed  Asymmetrical  Due to left
 Facial movements movements on one sided
is symmetrical side of face (left) weakness


Palpation Integrity  (-) tenderness  (-) tenderness  Normal

 (-) masses  (-) masses  Normal

Color  Varies  Gray hair (no artificial  Normal

Hair Inspection color) due to
Amount and  Evenly distributed aging
distribution  Evenly distributed  Normal
 Texture  Fine to coarse  Greasy hair
 four days
without a
bath due to
confineme
nt and
body
Presents of  (-) infestation  (-) infestation
weakness
parasites
 Normal

Eyelids and
Eyes Inspection eyelashes

Position and  (-) No drooping  (-) No drooping down  Normal

appearance down of eyelids of eyelids

 Eyelashes evenly  Eyelashes evenly

distributed distributed  Normal

 (-) ulcerative lesions  (-) ulcerative lesions  Normal

 (+) Blinking  (+) Blinking  Normal

Blinking symmetrical symmetrical

iris and pupil  Round  Round  Normal

Shape  Equal  Equal  Normal
Equality  (+) uniform eye  (+) uniform eye  Normal
color color(brown)
Color
(iris)
 Due to
Lens for  Clear  Clouding of the lens cataract
clarity of the eye

Size  Pupil size are equal  Pupil size are equal  Normal
 (2mm)

Conjunctiva  Bulbar conjunctiva  Bulbar conjunctiva is  Normal

is clear with tiny clear with tiny vessels
vessels ;palpebral ;palpebral conjunctiva
conjunctiva is pink is pink with no
with no discharge discharge
 Lack of
 (-) Periorbital  (+) Periorbital sleep
Puffiness Puffiness
Sclera  Normal
 Sclera is blue-white  White sclera with
slight yellowish
discoloration
Accommodati  Normal
 Pupils converge and  Pupils converge and
on
constrict as object constrict as object
moves in toward the moves in toward the
nose  Normal
nose
 Pupil responses are  Pupil responses are
uniform uniform
 CN 3
Extraocular  Both eyes move in a dysfunction
 Failure to follow
movement smooth, coordinated object with both eyes
manner in all
directions
Response to  Normal
light  Reflections of light  Reflections of light
noted at same noted at same
location on both location on both eyes
eyes
 External nose 
Inspection  Normal
Nose Skin  Color: same as face  Color: same as face
appearance (dark brown)

Shapes  Symmetrical  Symmetrical  Normal

appearance appearance

Nares  Symmetrical  Symmetrical  Normal

appearance appearance

Internal nose  Mucosa pink with  Mucosa pink with and  Normal
and moist with moist with uniform
Appearance uniform color and color and no lesions
no lesions
Landmark :Tur
binates,  Normal
septum  Turbinates and  Turbinates and
middle meatus are middle meatus are
visible and same visible and same
color as mucosa color as mucosa

 Free from lesions  Free from lesions  Normal

 Septum is  Septum is  Normal

symmetrical and symmetrical and
uniform without uniform without lesion
Palpation lesion

Patency
 Air is felt being  Air is felt being  Normal
Palpate
external nose exhaled through exhaled through
opposite nares opposite nares
  Normal
 Patient identify the  Patient identify the
presented odor presented odor while
while patient eye is patient eye is
covered covered (cotton balls
with alcohol)  Normal
Palpate  Solid placement; no  Solid placement; no
sinuses nodules,masses or nodules, masses or
pain reported on pain reported on
palpation palpation
 Normal
 Nontender on  Nontender on
palpation palpation  Normal

 (-) masses  (-) masses

Ears Inspection Size and  Equal size and  Equal size and  Normal
shape similar appearance similar appearance

 Pinna immediately  Pinna immediately  Normal

Recoil after it is Recoil after it is
folded folded
Lesions and  Skin smooth and  Skin smooth and  Normal
discoloration without nodules; without nodules; color
color pink pink
Cerumen  (+) ear wax  (+) ear wax  Normal

 (-) odor  (-) odor  Normal

 (-) purulent  (-) purulent discharge  Normal

discharge
Gross hearing
 Able to hear  Able to hear  Normal
ability
whispered words whispered words
from 1-2 feet from 1-2 feet
 CN 8
 Able to hear watch  Unable to hear watch dysfunction
tick from 1-2 inches tick from left ear
 Palpation Palpate  No tenderness or  No tenderness or
external ear pain when palpated pain when palpated  Normal

Mouth Inspection Inspect open

and closed  (-) lesions,  (+) slightly drooping  Due to
mouth for swelling ,drooping CVD
symmetry and
alignment

Lips  Reddish -pink to  Bluish lip color  Low blood

Color brown range level of
oxygen
 Moist, smooth with  Moist, smooth with no  Normal
Consistency no lesions lesions

Buccal
mucosa

Color  Pinkish  Pinkish  Normal

 Moist, smooth with  Moist, smooth with no  Normal

no lesions lesions

 (-) bleeding  (-) bleeding  Normal

Gums
 Due to
Color  Pink  Light black gums smoking

Teeth
 Due to
Number  32 teeth  28 teeth teeth
extraction
Position and  Stable fixation,  Jagged edges,  Due to
condition smooth surfaces teeth
and edges grinding
each other
 Dental carries located
at first and second  Poor oral
molar at lower jaw hygiene

Color  Pearly white and  Yellowish teeth  Due to

shiny excessive
coffee and
smoking
  Chalky white area is  Beginning
seen cavity

Tongue
 Moist ,symmetrical  Moist ,symmetrical  Normal
Symmetry and appearance ;midline appearance ;midline
texture fissures is present fissures is present
 Normal

Color  Pink  Pink

 Normal

Movement  (-) jerky movement  (-) jerky movement

 Normal
  (-)lesions ,frenulum  (-)lesions ,frenulum is
Landmarks is centered centered
 Normal
 Smooth swallowing  Hard time swallowing
Swallowing
 Muscle
weakness
due to
CVD

 Muscle
Verbal  (-) slurred speech  (-) slurred speech weakness
due to
CVD

Neck Inspection Color  Same color with the  Same color with the  Normal
face face (dark brown
complexion)
Symmetry  Symmetrical  Symmetrical  Normal

Appearance  (-) mass , lumps  (-) mass, lumps  Normal

swelling and lesion swelling and lesion
 Normal
Movement  Good range of  Limited ROM  Due to
motion stiffness on left side muscle
weakness
(left sided
weaknesse
s)
 Palpation
trachea

Position  Midline  Midline  Normal

position ;symmetric position ;symmetrical
al
Characteristic  No tenderness upon  Normal
 No tenderness upon palpation
palpation

Thyroid
glands

Position  Midline  Midline  Normal

Characteristic  Smooth, firm, Smooth, firm,  Normal

nontender nontender

Thorax Inspection  (+) symmetrical  (+) symmetrical

and Lungs expansion with expansion with  Normal
respiration respiration

Palpation  (+) tactile fremitus  (+) tactile fremitus  Normal


Percussion  (+) resonant sound  (+) resonant sound  Normal


 Auscultatio  (+) Normal vesicular  (+) Normal vesicular  Normal
n breathing sounds breathing sounds

Heart Auscultatio Rate and  (+) regular rhythm  (+) regular rhythm  Normal
n rhythm
(67 bpm)
 (-) Murmur are  (-) Murmur are heard  Normal
heard
 Regular cardiac
 Normal
rhythm, S1, and S2
are heard at all times.
 Distinct sound heard  Normal

in each area but

loudest in mitral and  Normal

tricuspid areas.

Upper Inspection  (-) redness  (-) redness  Normal

Extremities
 (-) swelling  (-) swelling  Normal

 Moist skin  Moist skin  Normal

  (-) lesion  (-) lesion  Normal

 (-) masses  (-) masses  Normal

Abdomen Inspection Integrity  (-) Scars  (-) Scars  Normal

 (-) rashes or lesions  (-) rashes or lesions  Normal
Contour  Flat  Flat  Normal
Symmetry  Symmetrical  Symmetrical  Normal


Auscultatio Bowel sounds  5-30 bowel sounds  17 bowel sounds of  Normal

n per minute clicks and gurgles
and occasional
borborygmus sounds
Vascular  No bruits ,no friction  No bruits ,no friction  Normal
sounds rub rub

Percussion
 Generalized  Generalized tympany  Normal
tympany over over bowels
bowels

Palpation Consistency  Smooth  Smooth  Normal

 (-) tenderness,  (-) tenderness,  Normal
masses, lesions, masses, lesions,
swelling swelling

Lower  (-) lesions  (-) lesions  Normal

Extremities Inspection

 Accident
 (-) Abrasion  (+) Small abrasion on due to loss
both legs of control
and
balance
while
driving

 Normal
Palpation  (-) masses, lesions  (-) masses, lesions

Skin Inspection Color  Uniform  Uniform  Normal

complexion complexion(dar
k brown )

Odor  No foul smelling  No foul smelling  Normal

odor odor
Integrity  (-) abrasion  (+) small  Accident
abrasion on the due to loss
left arm and of control
both legs and
balance
while
driving
 Bruises is seen
 (-) bruises in the left arm  Due to
accident
Skin turgor  Capillary refill
 Good capillary
time of 2  Normal
refill time

 (-) edema  (-) edema

  Normal

Palpation  (-) masses,  (-) masses,  Normal

lesions, lesions,
tenderness tenderness
 Color  Pinkish  Pale nails  Low blood
Nails Inspection fingernails and level of
toenails oxygen

Appearance  Short and clean  Short and dirty  Poor

nails nails both hygiene
fingernails and
toenails
Shape  Round nail with  Late clubbing of  Low blood
160 degree fingernails level of
oxygen

Palpation Texture  Nail is round  Thickened nails  Decrease

hard circulation

 1-2 sec  2 sec capillary  Normal

capillary refill refill time
time
GORDON’S 11 FUNCTIONAL HEALTH PATTERN

DATE OF INTERVIEW: April 1, 2023

TIME OF INTERVIEW: 1:00 am

Days of Confinement: 4 Days

LOC: Conscious and coherent

FUNCTIONAL HEALTH BEFORE DURING

PATTERN HOSPITALIZATION HOSPITALIZATION
HEALTH PERCEPTION According to the patient, being Patient stated that he will
AND MANAGEMENT healthy is vital because you can’t pay attention in his health
perform any activity while you are because when he was
sick. Patient has a history of old admitted he felt like he
lacunar infarct and hypertension can’t survive and feels
with a maintenance of Losartan, and like it was the end of his
patient also had a Diabetes Mellitus life because it was his
type II but doesn’t have any second time being
maintenance or treatment. he also admitted with the same
stated that he had asthma when he condition.
was a child and used meter dose
inhaler as his treatment. Patient
stated that he never takes food
supplements or any vitamins but
every time he felt pain he would
take an over the counter
medications to relieve his pain. The
patient mentioned that he smoked
for almost 20 years and decided to
stop last 2018, he is a heavy drinker
when he was young and
 occasionally drinks at the age of 40.
Patient have allergy in seafoods and
take cetirizine when his allergy
occur. He takes herbal medicine like
boiled lagundi leaves as his remedy
for cough.
NUTRITIONAL/ The patient states that he The patient stated he can
METABOLIC PATTERN consumes 2-3 cups of rice every
consume 350 ml of water
meal and sometimes he had 4
meals in a day. Before he was a day and consume
admitted for his first admission he
chucky as seen. He also
really love to consume sweets
especially chocolate drink like mentioned that he is
chucky, he can drink chucky every
eating fruits like apple.
day, he had a good appetite and he
prefer vegetables than red meat and
had no problem swallowing food. He
drinks water at least 1-2 liters a day
and he also like to drink coffee twice
a day
ELIMINATION PATTERN Before being hospitalized, he the patient is wearing
regularly defecates. twice a day.
diaper, can urinate with
Feces no difficulty, and was able
 Color: Not stated
to defecate twice since
 Texture: Not stated
admission.
he doesn’t have any difficulty in
defecating and urinating.

Urine
 Color: Dark Yellow
 Consistency: Yellow
 Odor: usually unnoticed by
the patient
EXERCISE AND According to the patient, he doesn’t Patients reported that he
 ACTIVITY PATTERN have a regular exercise since he
had a history of stroke. he stated
that his only exercise everyday is
driving a tricycle.
SLEEP/REST PATTERN The patient stated that he have at
least 6 hours of sleep every day, he
usually goes to bed at 10 pm
because he is watching television
programs and wake up at 4 am in
the morning to get ready for his
work
COGNITIVE The patient stated that he speaks
PERCEPTION PATTERN
Tagalog and Ilocano, he has a
hearing problem and complaining of
blurry vision at his left eye. he
cooperates and communicates
efficiently.
SELF PERCEPTION AND Patient bathe twice a day, he has no
SELF CONCEPT
history of plastic surgeries. patient
PATTERN
claimed that even though he is been
remains in bed all the
time due to body
weakness.
The patient claimed that
in his three days of
confinement he have a
proper sleep and rest
while in the hospital but
then in his fourth day of
confinement there is a
aggressive patient beside
his bed who is too noisy
that’s why he can’t sleep
properly.
The patient is delightful to
be around and responds
to all of the
healthcare personnel'
inquiries about him
He stated “parang wala
na akong silbi dahil
nandito nalang ako
 diagnosed with the complicated nakahiga at hindi ko pa
diseases he still trying to do his daily maigalaw ng maayos
activities. itong katawan ko,
pakiramdam ko pabigat
nalang ako sa mga anak
ko”

ROLE RELATIONSHIP The patient stated that he gets The patient's had his
PATTERN
along well with his neighbors and Son in law to take care of
family members. He also claimed him.
that even though he and his wife
separated they still had a good
relationship for the sake of their
children
SEXUALITY AND “noong magkasama pa kami ng No sexual intercourse
REPRODUCTIVE
asawa ko madalas kaming mag since admission and no
PATTERN
siping” as verbalized by the patient. problem in reproductive
Patient has no reproductive system is noted.
problems.
COPING AND STRESS Patient stated that if he has a he spends the most of his
TOLERANCE PATTERN
difficulty or is stressed because of time resting, lying down
his worries, he will just let is pass or and sleeping. He also
sometimes he will watch fun movies keep on praying and
to forget his problems. asked for guidance and
faster recovery
VALUE-BELIEF The patient is a roman catholic and The patient stated that his
PATTERN
he believes in any kinds of faith is bigger than her
“pamahiin” and ghost. problems.