Lyceum-Northwestern University

Francisco Q Duque Medical Foundation

Dagupan City, Pangasinan
College of Medicine

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I. GENERAL DATA
Patient I.S. 47 year old, Female from Buenavista, Umingan, Pangasinan, and
Roman Catholic was admitted for the first time at Region 1 Medical Center
Source of information:
Patient
Reliability: 90%
II. CHIEF COMPLAINT:
Generalized right sided weakness
III. HISTORY OF PRESENT ILLNESS
3 days prior to admission while the patient was at work at 8AM in the morning,
she suddenly felt warm in her right side of her body, she felt an increase in body
temperature which was not measured, and a feeling of right sided facial swelling.
The patient went home and rested and took her meal. At noon right around 12
o’clock the patient tried to get up from her bed but was unable to do so which
prompted her together with her husband to go to Umingan Community Hospital.

On their way to the Umingan Community Hospital, the patient felt a sudden right
sided upper and lower body pain graded as 5/10, her husband also noted that
while on their way to the hospital he noticed that she has slurring of speech; they
were entertained in Umingan Community Hospital then later was referred to
Region 1 Medical Center for a more extensive management.

IV. PAST MEDICAL HISTORY

Patient was previously hospitalized in 2008 at Philippine Heart Center in Quezon
City for due to shortness of breath and eventually mild stroke. No allergies to
food, medications or pollens. No other history of surgical interventions. No
asthma, chicken pox.
V. REVIEW OF SYSTEMS

General (-) weight gain/loss (+)irritability (-) Poor Oral Intake

(+)weakness
Cutaneous (-) rash (-) lumps (-) pruritus (-) dryness
Head (-) dizziness (-) light-headedness (-) syncope (-)headache
Eyes (-) pain (-) blurred vision (-) diplopia
Ears (-) hearing problem (-) ear pain
Nose (-) colds (-) nosebleeds
Mouth & Throat (-) bleeding gums (-) dysphagia
Neck (-) lumps (-) stiffness
Respiratory (-) chest pain (-) cough (-) dyspnea
Cardiovascular (-) chest pain (-) palpitations (-) dyspnea (-) easy fatigability
Gastrointestinal (-) nausea (-) vomiting (-)abdominal pain (-) dysphagia
(-) hematemesis (-) diarrhea (-) constipation
Renal (-) dysuria (-) polyuria (-) oliguria (-) urinary incontinence
Genitalia (-) pain (-) swelling (-) discharge
Peripheral Vascular (-) leg cramps (-) leg claudication
Endocrine (-) polydipsia (-) polyphagia (-) excessive sweating
(-) cold / heat intolerance
Musculoskeletal (+) muscle weakness (-) Backache (-) muscle pain (-) joint pain
Hematologic (-) pallor (-) easy bruising (-) bleeding
Behavioral (-) longer duration of sleep (-) anxiety (-) mood changes

VI. FAMILY HISTORY

The patient Husband is a farmer, a non-smoker and an occasional alcohol drinker
usually consuming 3-5 bottles of beer or a half liter of gin per week. Her daughter
aged 21yrs old currently a grade 12 senior high student at Flores Umingan School.
There is no history of hypertension, diabetes, asthma, tuberculosis on maternal
and paternal side. No other heredofamilial diseases noted.

VII. SOCIOECONOMIC HISTORY

The patient lives in bungalow made of Concrete with her Husband and Daughter
located far from the central business district. Their waste disposal method is thru
garbage collection; water source comes from NAWASA, patients usual diet
consist of meat (chicken, pork, beef) and rice with occasional food of fish.

VIII. OBGYNE HISTORY

Patient is G1P1 (1-0-0-1) Menarch at age 13 with regular menses with 3- 4 days
duration with normal to heavy flow, usually using 4 pads without history of
intermenstrual spotting, , her LMP was on December 2019. No history of using
contraceptive methods and pills. No history of gynecologic illness and no Pap
smear test done.
 IX. PHYSICAL EXAM
Vital Signs
Blood Pressure: 120/70 Respiratory Rate: 30 Cardiac rate: 92
Temperature: 36.6 ºC SpO2: 94

The patient is conscious, coherent and oriented to time, place and person. She is lying on the bed.
She cooperates well during interview and physical assessment

HEAD:
Head is symmetric, with good contour, no lumps nor lesions. Non tender sinuses upon palpation

EYES:
Good alignment, icteric sclera, 3mm pupil size,

EARS:
Aligned, no deformities, no discharge

NOSE:
Symmetric, patent no septal deviation. Patent bilateral nares and negative discharge. No mass nor
lesions.

NECK:
No lumps nor lesions, no tenderness no palpable lymph nodes, no jugular venous distention

SKIN:
Fair complexion. No pallor, cyanosis or jaundice. No Rashes. No petechiae, scar or edema.
Warm to touch and good skin turgor.
CHEST:
Symmetrical; no retractions; no lag; no spider angiomas; equal vocal and tactile fremiti; equally
resonant on both lung fields; equal breath sounds; no rales; no wheezes

ABDOMEN:
Flabby abdomen, non-distended, no mass, no striae, no caput medusae, no visible pulsation,
normoactive bowel sounds of 26 bowel sounds per minute at the right lower quadrant and no
bruit no abdominal aorta heard with 8.5cm liver span

HEART:
Adynamic precordium ; Apex beat at the 4 th or 5th intercostal space left midclavicular line ;
negative thrills/ heaves ; no loud and palpable P2 ; normally split S2 ; S1 > S2 at apex ; S2 > S1
base ; negative S3 ; negative S4 ; normal rate regular rhythm, no murmurs

NEUROLOGICAL:
Cerebrum: alert, awake, coherent
Cerebellum: no tremors, no nystagmus, no unpurposefull movement
SENSORY MOTOR
 10% 90% 1/5 4/5

10% 90% 1/5 4/5

CRANIAL NERVES:
CN I: able to identify odor of alcohol
CN II: The patient can see, able to fixed eyes on an object and follow its movement.
CN III, IV, VI: No ptosis. Positive EOMs. Pupils are equally round and reactive to light
and accommodation
CN V: Facial sensations are intact.
CN VII: No facial asymmetry was noted.
CN VIII: Patient was able to hear and respond when being talked to.
CN IX, X: able to swallow and positive gag reflex
CN XI: Patient was able to move head side to side; patient can shrug shoulders against
resistance
CN XII: patient protrude tongue in midline
NEUROLOGICAL:
Cerebrum: alert, awake, coherent
Cerebellum: no tremors, no nystagmus, no unpurposefull movement
Sensory: can identify sharp from dull sensation on all extremities

IMPRESSION/DIAGNOSIS:
Cerebrovascular Accident / Transient Ischemic Attack
Kindly comment on the said Clinical History and Physical examination of this Patient.

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