Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
24 Hour History
GENERAL DATA:
This is a case of Jamela Edgardo, 55 year old, male , Filipino, Currently residing in
Blk 69,lot 52 PH 1, SU5A, Brgy. Lang Kiwa,Binan,Laguna, admitted in our institution on 23
September, 2017.
CHIEF COMPLAINT:
Left sided weakness.
REVIEW OF SYSTEM
CNS: (-) loss of consciousness (-) headache (-) dizziness
INTEGUMENTARY: (-) pruritus
RESPIRATORY: (-) hemoptysis, (-) dyspnea, (-) DOB
CVS: (-) chest pain/discomfort, (-) palpitations, (-) orthopnea, (-) paroxysmal nocturnal
dyspnea
GIT: (-) heart burn, (-) decrease appetite, (-) nausea, (-) vomiting, (-) bowel movement, (-
) change in bowel habits, (-) melena, (-) change in color of stool,
GUT: (-) polyuria, (-) oliguria (-) nocturia, (-) urgency, (+) dysuria, (-) hematuria, (-)
incontinence
MUSCULOSKELETAL: (-) limitation in movement
HEMATOLOGIC: (-) easy bruising, (-) bleeding of the hemangioma
PHYSICAL EXAMINATION:
General Survey: conscious, coherent, not in cardiorespiratory distress
Vital Signs:
BP: 110/70 mmHg PR: 67bpm RR: 22cpm Temp: 36.10C
Skin: Warm to touch, senile skin turgor, (-) rashes, (-) Active dermatomes
HEENT: No deformities, no masses, no facial edema, anicteric sclera, pink palpebral
conjunctivae, no nasoaural discharge, no tonsillopharyngeal congestion, no cervical
lymphadenopathy,
Chest/Lungs: Symmetrical chest expansion, no retraction, (+)crackles
Heart: Adynamic precordium, no thrills, no heaves, normal rate, regular rhythm, no murmur
Abdomen: Flabby, normoactive bowel sound, (-) abdominal tenderness
Extremities: No gross deformities, full and equal pulses, (-) cyanosis, (-) edema
Neurologic Exam:
Cerebrum: oriented to time place and person
CN I – not assessed
CN II – 2-3 mm reactive to light stimulation
CN III, IV, VI – intact extraocular muscle
CN V – can clench teeth
CN VII – no facial asymmetry
CN VIII – can hear
CN IX, X – can swallow
CN XI – can shrug shoulder
CN XII – tongue at the midline
ASSESSMENT:
PLAN
➢ Diet: low salt,low fat,renal diet with high biologic value protein
➢ IVF: PNSS 1L×40 CC/hour
MEDICATIONS:
Ceftriaxone 1 gm IV Quh
Paracetamol 500 mg 1 tab Quh
Azithromycin 500 mg 1 tab OD for 3 days
N-Acetyl Cysteine 600 mg/200 mg in 75 ml water
Ipratropium+Fenoterol(Berodual)nebulizer 2 inhalations QID
Telmisartan 80mg/tab ,1 tab OD
Verapmil 240 mg/tab,1 tab OD
Clopidogrel 75 mg/tab,1 tab OD
JI HAKKAPAKKI SANGEETHA
IM CLERK IN CHARGE