II.

ASSESSMENT

• Patient’s Profile

> Mrs. C. B.

> 70 years old

> Female

> Widowed

> RC

> Montalban, Rizal

• Present History

1 day prior to admission, Mrs. C. B. suddenly developed right sided

body weakness with no accompanying symptoms like slurring of speech,

decrease in sensorium, vomiting, and headache. Her relative gave her

pineapple juice, which apparently relieved the symptoms. At 6am on the

day of admission, symptoms recurred now accompanied by inability to

speak, decrease in sensorium, headache, and vomiting of two episodes.

She brought immediately to the institution and subsequently admitted.

• Past History

Mrs. C. B. was known to be hypertensive for 30 yrs. She was not

known to have DM, PTB, asthma, heart, thyroid, or kidney disease

according to her daughter.

• Family History

Patient’s third sibling known to have a DM and her eight sibling was

positive in HPN. She acquired hypertension to his mother who already

died.

GENOGRAM

patient

LEGEND:

Male Female

Male-deceased Female-deceased

With HPN With DM

• Social History

Mrs. C. B. was a farmer and a vendor of vegetables. She was nice

to everybody according to his daughter. After her work, she will chat to his

friends as a means of resting.