I.

DEMOGRAPHIC DATA

Patient X is 80 y.o., male, and widowed. He was born on November 29, 1930. He currently resides together with his eldest son and grandchildren at 32. F, Gorordo Ave. Camputhaw, Cebu City. He is a pure Filipino, and is religiously affiliated as a Roman Catholic. He is a retired AFP, and was admitted at Perpetual Succour Hospital on September 19, 2011 for the 3rd time, because of slurring of speech. He was attended by Dr. Edwin Tiempo and Dr. Renan Dungog. The source of reliability of information was his eldest son and his caregiver.

II. PATIENTS HISTORY

a. Chief Complaint On September 19, 2011 at 4:32pm patient X came in to ER of Perpetual Succour Hospital due to slurring of speech. With baseline vital signs of: T-36.6 C, PR: 88 bpm, RR: 18 cpm, BP: 160/80 mmHg, WT: 64.5 kg b. Present Illness One day prior to admission, patient had onset of slurring of speech associated with body malaise, no headache, shortness of breath, chest pain, paralysis, loss of consciousness noted. No consult done. Persistence of slurring of speech prompted consult and subsequent admission. He was admitted at Perpetual Succour Hospital on September 19, 2011 at 4:32pm for the 3rd time, with vital signs of: T-36.6 C, PR: 88 bpm, RR: 18 cpm, BP: 160/80 mmHg. He is currently on a speech therapy. c. Past History of Illness Patient X had his first hospitalization 13 years ago, wherein he had undergone an operation which is Prostatetectomy in the same hospital. According to his son, the patient discovered he has Diabetes Mellitus Type II and Hypertension 10 years ago and was hospitalized for the 2nd time. Maintenance medications used were: Norvage 10mg PO, OD, Platexan

OD, and Janumet, BID and with good compliance. The patient is a nonsmoker and non-alcoholic drinker and he doesnt have any allergies in medicines, foods, and the environment.

d. Familial History
Grandfather Deceased HPN Grandmoth er Deceased d/t aging Grandfather Deceased Heart attack

Grandmoth er Deceased DM Type 2

Father Deceased Stroke Mother Deceased HPN

Patient X HPN/CVD/DM Type 2

Sister 1 DM

Sister 2 Normal

Brother DM/HPN

Sister 3 HPN

They have history of Hypertension, Diabetes Mellitus and Heart Diseases.