BIOGRAPHIC DATA

Name: Mr. LVD

Age: 45
Address: Balanga, Bataan
Civil Status: Married
Birthday: Jan 16, 1974
Nationality: Filipino
Religion: Catholic
Occupation: Delivery Truck Driver

Attending Physician:

Chief Complaint: 2 days prior to admission, patient experienced sudden onset of left-sided body
weakness with headache and nausea and vomiting.

Admitting Diagnosis: Cerebrovascular Accident

NURSING HISTORY

Childhood Illness:
According to the patient, he had chicken pox, fever, cough and colds when she was young.

Immunizations:
The patient does not remember whether he had a complete immunization.

Allergies:
Patient has no known allergy.

Accidents:
Patient does not have a history of accident.

Foreign Travel:
Patient does not have a history of foreign travel.

Hospitalization:
Patient has never been hospitalized.

6
 Family History

Mother Father
(+) Hypertension (+) Hypertension
(+) D.M. type II (+) D.M. type II

PRESENT HEALTH HISTORY

Patient experienced a sudden onset of left sided body weakness, nausea, vomiting and
slurred speech, and headache two days prior to admission. Patient was not able to work for two
days because of the left sided body weakness, headache, and nausea and vomiting. He was
brought to the Emergency Room of Bataan General Hospital and Medical Center at around 9:45
AM of May 15, 2019. He was later admitted to the Male Medical Ward at around 11:50AM with
an admitting diagnosis of Cerebrovascular Accident. The diagnosis was then changed to
Malignant Right Middle Cerebral Artery Infarction after a series of examination. Patient was
requested to be transferred to the Neuro Science Unit of the same hospital at 2:00 PM but was
not transferred until 5:00 PM of the same day. Patient was diagnosed with Diabetes Mellitus
Type II five years ago and has not been recently adhering to medication regimen. Patient is
currently confined at the Neuro Science Unit of Bataan General Hospital and Medical Center.