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Patients Profile: Name: Address: Age: Gender: Religion: Civil Status: Occupation: Date of Admission: Admitting Physician: Admitting

Diagnosis:

Mrs. SMT Gen. Trias, Cavite 35 years of age Female Catholic Single None Dec. 6, 2011 Dr. Villamor Hypertension t/c Stroke in Evolution

Reliable source of information/ Informant: Patient himself/ Patients records Reason for seeking care: Slurring speech Patient Medical History (Past and Present): A. Pediatric and Adult Illness Patient does not recall any past illness during her childhood. No record of any allergies noted. Few minutes PTC patient experienced numbness in her right arm and slurring of speech. (-) Edema, (-) Facial asymmetry. B. Immunization Patient claims she has complete immunization according to her mother. Social and Personal History (Based on Gordons functional pattern)

1. Health perception and Management- Clients initial choice of treatment is through a known
albularyo which aggravated her condition with burns. Nutritional and Metabolic pattern- Familys choice of food is usually meat and vegetables, in which they prefer fried or foods rich in NA+ and fats. 3. Elimination pattern- Patient claims to have a regular bowel movement and urinating pattern. 4. Activity-Exercise Pattern- Patient claims she usually takes early morning walks as a method of exercise. 5. Sleep-Rest pattern- Client usually sleeps 6-8 hours every night and does mid day siesta after eating lunch. 6. Cognitive and Perceptual pattern- Client is very much aware of her situation and understands the explanation given to her by her physician. 7. Self-Perception and Self-Concept pattern- Prior to confinement patient claims she was a healthy individual. 8. Role- Relationship pattern- Client is a proud mother of three and says she is a dutiful wife, and an active member if the community 9. Sexuality-Reproductive pattern-Prior to confinement client has a healthy reproductive life. 10. Coping- Stress Tolerance pattern- Client usually watches T.V. as a mode of relaxation after a busy day. 11. Value- Belief pattern- Client is a devout catholic and goes to church every Sunday. 2. Physical Examination Clients overall appearance is good, head is round and no palpable mass noted. Eyes are free of conjunctiva. Ears are symmetrical. No facial asymmetry noted. Speech is slurred. No palpable nodes in the neck area. No notable lung sounds. Has soft non-tender abdomen. Right side extremities are weak. Negative edema on both upper and lower extremities. Anatomy and Physiology The anatomy of the brain is complex due its intricate structure and function. This amazing organ acts as a control center by receiving, interpreting, and directing sensory information throughout the body. There are three major divisions of the brain. They are the forebrain, the midbrain, and the hindbrain. The forebrain is responsible for a variety of functions including receiving and processing sensory information,

thinking, perceiving, producing and understanding language, and controlling motor function. There are two major divisions of forebrain: the diencephalon and the telencephalon. The diencephalon contains structures such as the thalamus and hypothalamus which are responsible for such functions as motor control, relaying sensory information, and controlling autonomic functions. The telencephalon contains the largest part of the brain, the cerebrum. Most of the actual information processing in the brain takes place in the cerebral cortex. The midbrain and the hindbrain together make up the brainstem. The midbrain is the portion of the brainstem that connects the hindbrain and the forebrain. This region of the brain is involved in auditory and visual responses as well as motor function. The hindbrain extends from the spinal cord and is composed of the metencephalon and myelencephalon. The metencephalon contains structures such as the pons and cerebellum. These regions assist in maintaining balance and equilibrium, movement coordination, and the conduction of sensory information. The myelencephalon is composed of the medulla oblongata which is responsible for controlling such autonomic functions as breathing, heart rate, and digestion.

Test FBS Cholesterol Triglycerides HDL LDL

Result 4.9 3.0 0.5 21.9 84.8

Reference Range 3.08-6.06 mmol/L 3.0-602 mmol/L 0.40-1.86 mmol/L 30-75 mg/dl 60-178 mg/dl

Diagnostic / Lab Results


Clinical Chemistry Test BUN Creatinine Sodium Postassium Chloride Result 3.5 99.7 139.2 3.47 105.3 Normal Values 1.2-4.3 mmol/L 44.2-150.3 mmol/L 135-145 mmol/L 3.5-5.6 mmol/L 96-106 mmol/L

Drug a. b. c. d. Diet:

Study Clonidine 75mg. SL PRN for BP >150/100 Cilostazol 100mg BID PO Citicholine 1G IVP q12 Citicholine 500mg TID PO Low salt, Low fat diet

Discharge plan: Medication a. Clonidine 75mg. SL PRN for BP >150/100 b. Cilostazol 100mg BID PO c. Citicholine 1G IVP q12 d. Citicholine 500mg TID PO Exercisea. Walking (assisted) b. Range of Motion exercise Treatment a. Rehabilitation b. Speech therapy Health teaching a. Avoid food which are salty and fatty b. Take medication on time c. Comply with follow-up schedule Out patient follow up a. After 7 days from the discharge date Diet a. Low salt, Low fat diet Spiritual a. Provide need spiritual support according to preference

Hypertension t/c Stroke in Evolution


Case Study
Submitted By:

Jiffy Y. Na-ong
BSN 4-2 / Group 3

Submitted To:

Josephine Abad, RN, MAN


GEAMH