Speech therapy

Rehabilitation Service
HFC Santa Barbara

ADULT NEUROLOGICAL PATIENT Anamnesis

1. ID
Full name : Juan Luis Troncoso Ríos
Birthdate : 02/06/81 Age : 35 years
Occupation : I took care of pigs Scholarship : 6th
Home :
Phone : 57685838 RUT:
Reason for consultation :
Derived by :

2. Personal history
Family group : Lady, two daughters and in-laws
Previous activities : I took care of pigs
Previous emotional state: Appropriate
Reading : No Writing : No
Manual dominance: Right x Left Ambidextrous

3. Medical history
Concomitant pathologies: HTA Diabetes Other(
s)
Previous neurological pathologies: stroke Other(s)
Previous table data:
Associated symptoms:
Medicines : Kopodex
Therapy: Kinesics

4. Morbid Family History

HTA:
Diabetes :
ACV:
Others) :

5. Description of the painting

Medical diagnostic : intracerebral hemorrhage
Start date : 16/03/17
Beginning :
Main symptom:
Associated symptoms: Engines x Comp. Awareness
Sensitive x Headache
Language Nausea and
vomiting
Dizziness and Swallowing
vertigo
Associated Disorders: Loss of Weightloss Others

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 Speech therapy
Rehabilitation Service
HFC Santa Barbara

appetite
Surgeries: A leg,
Treatment(s) : kinesic

6. Current background
Consciousness state : Adequate
Emotional state : Appropriate
Swallowing: Appropriate
Communication : Appropriate
Informant: Patient x Companion
Relationshi Name:
p:

7. Current power
Modality: Enteral: Parental Oral x
SNG
SNY
Gastrostomy
Consistency Solids x Semi-solid x Liquids x
It is fed in the following way: Dependent Semi-dependent Independent x
Frequency between meals:
Quantities:
Duration:
Foods to avoid: None
Swallowing facilitators:

8. Observations

________________________
Speech therapist

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 Speech therapy
Rehabilitation Service
HFC Santa Barbara

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