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CEREBRO VASCULAR ACCIDENT

CASE PRESENTATION 414 A&B

Patients Profile
NAME: EDGARDO DIAZ ADDRESS: Batasan Hills Quezon City AGE: 50 years old BIRTHDAY: July 20, 1962 HEIGHT: 5 8 WEIGHT: 240 lbs. MARITAL STATUS: Married RELIGION: Roman Catholic OCCUPATION: Taxi Driver HOBBIES: Playing Basketball

PAST MEDICAL HISTORY:


Upon assessment patient H,S stated that hes not quite sure of the vaccination given to him during his childhood. He also stated that he has NO allergies in any medication but he has an allergies in seafood particularly in shrimp. As far as past illness is concerned he has only experience a mild COUGH, COLD, FEVER & FLUE when he was a child. In terms of past Medical History patient H.S stated that he never occur in any injuries that requires Medical or Surgical treatment during those days. He also stated that this is the very first time to ask a medical assistance.

FAMILY HISTORY:
In terms of Family History patient H.S stated that both of his Biological parents had a history of Hypertension, Diabetes, and Heart disease as well as the other family member has been diagnosed with that particular disease.

PRESENT MEDICAL HISTORY:


In spite of patient H.S family history he never attempts to seek any medical assistance. As part of his daily routine in life as a taxi driver for almost 11 years he loves to eat fatty and salty food that always offered in the carinderia. His job requires a long hour to complete his duty in a day. To stay awake he takes a cup of coffee and smoke that consumes two packs of cigarettes a day. Until one day on October 12, 2012 early in the morning when patient H.S is going to garage to off his duty he felt numbness on the left side of his leg and accompanied by a mild headache.

As initial action of patient H.S he took a nap thinking that he is tired with a long a long hour of duty. At around 8:30 in the morning patients H.S co-worker try to awake him up but unfortunately he doesnt wake at all. so they decided to rush him in the hospital. Patient H.S is admitted to Quezon City General Hospital last October 12, 2012 at around 9:15 am. He was admitted to the Emergency ward due to his condition the attending physician advised to have a CT-Scan.and some series of test such as CBC, LFT, SGPT, U/A, UTZ, BUN, and CREATININE to confirm the initial diagnose of Cerebro Vascular Accident (CVD).

SOCIAL HISTORY:
Based on the assessment conducted by the health care provider patient H.S loves to eat a fatty and salty food. Hes a social drinker, coffee lover, and a heavy smoker as part of his daily life for almost 30 years as a stated by his wife. As a taxi driver 4 hours of sleep is consider good enough for his next duty. He doesnt take any medication or vitamin to boost his immune system.

DISCHARGE PLANNING

MEDICATION:
Instruct patient to take Telmisartan once a day 40mg orally take it without meal Anti-hypertensive (Angiotensin II receptor antagonist) Blocks the binding of Angiotensin II to specific tissue receptor found in the vascular smooth muscle and adrenal gland. Instruct patient to take Atorvastatin once a day 80 mg oral at bedtime take it without meal. Anti-hyperlipidemia (Adjunct to diet in treatment of elevated total cholesterol) Instruct client to apply Mupirocin Ointment three times a day every 4 hours. (8am, 12noon, 4pm) It is an antibiotic that works by stopping the growth of certain bacteria.

EXERCISE:
Passive Range of Motion as prescribed by the physician.

TREATMENT:
Continue home medications as ordered by physician. Instruct patient to monitor blood sugar early in the morning before meal. Describe the importance of regular taking of prescribed medication.

HEALTH TEACHING:
Explain the underlying disorder and treatment plan. Lifestyle change such as stop smoking eats healthy foods and avoids drinking of alcohol. General health measures (adequate sleep, proper diet, and maintaining a clean surrounding). Instruct patient to have an adequate sleep atleast 8 hrs a day Monitor blood pressure as well as blood sugar regularly.

Know the FAST test to recognize the signs of a stroke:


F = Face: Ask the person to smile. Drooping on 1 side of the mouth or face is a sign of a stroke. A = Arms: Ask the person to raise both arms. One arm that slowly comes back down or cannot be raised is a sign of a stroke. S = Speech: Ask the person to repeat a simple sentence that you say first. Speech that is slurred or sounds strange is a sign of a stroke. T = Time: Call the physician if you see any of these signs. This is an emergency.

OUT PATIENT:
Continues follow up care schedule Return again after a month for follow up check up Consult the physician for any problem or any complication encountered

DIET:
Maintain low fat low protein, and low salt diet.

SPIRITUAL:
Supporting religious practice. Assisst client with prayer. Refer client for spiritual counselling.