CHAPTER I

PATIENT’S 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 level
Date 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
 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 to
pay their hospital bills of his husband, but still they can’t 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.
 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
 • The patient eyes were isochoric. He is positive in doll’s 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 patient’s motor response has score of 1, which
means no motor response maid during course of admission.
H. Integumentary System
• The patient has poor skin turgor. No edema on the site. With skin lesions
on both feet.