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CHAPTER I

PATIENTS DATA

A. Personal Profile

Name : Mr. X

Age : 43 years old

Gender : Male

Height : 5`6

Weight : 185 lbs

Civil Status : Single

Date of Birth : September 29, 1963

Birth Place : Makilala

Religion : Roman Catholic

Nationality : Filipino

Origin (hometown) : Dona Assumption St. Prk. 9, Sasa, Davao City

Educational attainment : High school levelDate of Admission : January 16, 2010 (8:01 PM)

Attending Physician : Dr. Emerson Taghoy

Chief Complain : Hypertension

Impression : CVA BLEED MIDDLE CEREBRAL ARTERY 1

DEGREE HPN ST. II

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B. Family Background

Last February 9, 2009 we gathered the family health history of our client,

Mr. Ernesto S. Oliverio through his wife Mrs. Lucita B. Oliverio.

Mr. Ernesto S. Oliverio a 73 years old, married and a full pledged Roman

Catholic at birth. He is the youngest among the seven (7) siblings in their family.

His spouse name is Mrs. Lucita B. Oliverio a housewife. They are residing at

Dona Assumption St. Prk. 9, Sasa, Davao City and has blessed with five (5)

children. He is known to be a pensioner under the membership of SSS and a

PHILHEALTH member. He is a retired employee in the government as a

maintenance worker. And his wife has a mini sari-sari store to sustain their daily

needs. Hypertension is the heredofamilial disease of his parents.

C. Effects of Present Disease self/family

According to his wife Mrs. Lucita B. Oliverio the PHILHEALTH will help topay their hospital bills of his husband, but still they cant even afford to buy all

the medicines to his husband maintenance. The family was greatly affected

and worried for their father hospitalization, they hopes and prays that his

husband will recover sooner. They are waiting for him at home and give him

comfort measures that they could extend much of their care to be his beloved

husband.

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D. History of Past-illness

E. History of Present-illness

F. Assessment

February 09, 2009 @ 1pm

A. Vital signs

B. Neurological

Upon monitoring

Eye/Vision

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The patient eyes were isochoric. He is positive in dolls eye and is positive

in corneal reflux.

Ear/Hearing

Patient cannot hear audible sound. No discharge on both ears.

Mouth/tongue/teeth/speech

Patient is slurring of speech, he can eat and drink with his mouth and

cannot use his facial expression. He has dry, cracked and pale lips.

Tongue is rough and with whitish spots. The patient has missing teeth in

right area.

C. Cardiovascular System

The patient has normal rate of . With an abnormal pulse rate of .

with normal capillary refill of 2 seconds.

D. Respiratory System

The patient is in normal Respiratory rate of 23 beats per minute.

E. Gastrointestinal System

F. Genitourinary System

Patient has a Foley catheter; draining with light yellow colored urine less

than 30 cc/hour in amount.

G. Musculoskeletal System The patient was noted right-sided weakness and inability to walk during

admission. But now, the patients motor response has score of 1, which

means no motor response maid during course of admission.

H. Integumentary System

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The patient has poor skin turgor. No edema on the site. With skin lesions

on both feet.