FEU DR.

NICANOR REYES MEDICAL FOUNDATION MEDICAL CENTER

Regalado Avenue, corner Dahlia Street West Fairview, Quezon City 1118
Tel. No.: 427-0213
DEPARTMENT OF INTERNAL MEDICINE
CLINICAL HISTORY
December 17, 2015

Informant:
Reliability: 85%

GENERAL DATA:
Forsales, Adolfo Nuez, 62 years old, male, single, Filipino, Christian, born on
July 17, 1953, presently residing on Visayas St, Batasan Hills, Quezon City, admitted
for the 2nd time to FEU- NRMF Medical Center on December 1, 2015.
CHIEF COMPLAINT: loss of consciousness
HISTORY OF PRESENT ILLNESS:
The history present illness started six hours prior to admission when patient
was found lying on the floor, slightly conscious and with incomprehensible words and
groaning with associated right-sided body weakness. No associated signs and
symptoms such as nausea or vomiting. Patient was then rushed to the Emergency
Department of FEU-NRMF Medicine where he was subsequently admitted.
PAST MEDICAL HISTORY:
2012, Myocardial Infarction, admitted in the Intensive Care Unit of FEU-NRMF
Medicine
2012, Cerebrovascular Accident
2012, Angiogram done at Philippine Heart Center, advised angiography but patient
declined due to financial constraint
1995, Diagnosed with Hypertension, patient was prescribed with anti-hypertensive
drugs but he was not compliant due to patients preference.
No History of Diabetes, Thyroid disease, Asthma, nor Allergy
Family History:
Father: Diseased, due to a cerebrovascular accident, and was known hypertensive
Mother: Diseased, died due to pneumonia
Patient is the 5th among 6 children; Sister was deceased due to breast cancer
Patient has 4 children, all apparently well
Personal and Social History:
Patient is a retired private employee, lives in a bungalow type house with electric
lighting. Water supply comes from Maynilad. Drinking water is purified. Patient
usually sleeps for 3-5 hours. Biodegradable garbage is collected twice a week and
non-biodegradable garbage is collected once a week. Patient was a 12-pack year
smoker and a previous alcoholic beverage drinker. Patient has no form of exercise.
REVIEW OF SYSTEMS:
Constitutional symptoms: (-) fever, (-) chills,
Skin: (-) itchiness, (-) excessive sweating, (-) cyanosis, (-) pallor, (-) jaundice, (-)
erythema, (-) dry skin
Head: (-) dizziness (-) headache, (-) vertigo
Eyes: (-) blurring of vision (-) excessive lacrimation (-) photophobia

Ears: (-) earache, (-) deafness, (-) tinnitus, (-) ear discharge, (-) ear itchiness
Mouth & Throat: (-) dry lips and tounge, (-) sore throat, (-) toothache, (-) gum
bleeding, (-) disturbance in taste
Neck: (-) mass, (-) neck vein engorgement
Respiratory: (-) plueritic chest pain, (-) cough
Cardiovascular: (-) palpitations, (-) syncope
Gastrointestinal: (-) loss of appetite, (-) abdominal pain, (-) nausea, (-) vomiting,
Genitourinary: (-) dysuria, (-) urinary frequency, (-) urgency, (-) hematuria. (-)
nocturia
Extremities: (-) swelling of joints
Nervous: (-) headache, (-) vertigo, (-) syncope, (-) numbness, (+) loss of
consciousness
Hematologic: (-) pallor, (-) easy bruising
Endocrine: (-) intolerance to heat & cold, (-) polydipsia, (-) polyuria
PHYSICAL EXAMINATION
General survey: unconscious, afebrile, not in cardiorespiratory distress with no
signs of dehydration
BP: 220/140
CR: 120 bpm
O2 Saturation: 97%

RR: Assisted

Temp: 36.5C

HEENT: pink palpebral conjunctivae, white sclera, pink nasal turbinates, moist lips
and buccal mucosa pink pharyngeal wall,
ck: Supple, no palpable lymph nodes and masses
Chest/Lungs: with supraclavicular retractions and bibasal crackles
Heart: Adynamic precordium, tachycardic at 120bpm, with regular rhythm, no
murmur
GIT: globular, distended, no palpable mass
ties: No gross deformities, full and eqaul pulses, capillary refill time <2 seconds
Skin: No active dermatoses
NEUROLOGIC EXAMINATION:
Cerebrum: GCS of 3 (E1V1M1), unconscious
Cerebellum: No nystagmus, gait not assessed
Cranial Nerves:
I: not assessed
II: 2-3mm pupils equally reactive to light
III, IV and VI: Intact extraocular muscles
V: with corneal reflex
VII: No facial assymetry
VIII: can not be assessed
IX and X: can not be assessed
XI: not assessed
XII: not assessed

MOTOR
assessed
1/5
1/5
1/5
1/5

SENSORY: not assessed

DTR: not

Meningeal signs: No nuchal rigidity, (-) Kernig, (-) Brudzinski

Pathologic reflexes: (+) Babinski

NEUROLOGIC EXAMINATION
Cerebrum: Patient is conscious, awake, oriented to time place and person, can talk
spontaneously and follow verbal commands. GCS score of 15 (E4V5M6)
Cerebellum: No nystagmus, no intention tremors, (-) Rombergs sign, (-) tactile
agnosia, can follow simple instructions and answer questions, can do finger-to-nose
test
Cranial nerves:
CN I: can smell coffee
CN II: ophthalmoscopic findings: (+) ROR and (+) direct and indirect light reflex, AV
ratio 2:3
CN III, IV, & VI: Intact EOMs, no ptosis
CN V: (+) corneal reflex, bilateral; can clench teeth equally on both sides, can
distinguish light touch, with pain sensation, can open and close mouth without
difficulty
CN VII: No facial asymmetry closes eyes tightly, can raise eyebrow, can frown
CN VIII: (-) lateralization in Webers Test; AC>BC in Rinnes Test
CN IX and X: (+) swallowing; (+) gag reflex; uvula at midline
CN XI: can shrug both shoulders but with weakness on the right
CN XII: Tongue deviated to the right upon protrusion

3/5

5/5 N/
100

10

3/5

5/5 100

100

Assessment:
Acute ischemic infarction, Left Corona Radiata and Posterior Limb of Internal
Capsule

Plan On Admission:
Elevate head of bed 30 degrees, refer for neuro evaluation, complete neuro PE
and History
Diet: low salt, low fat with SAP
IVF: PNSS x 60cc/hr
Diagnostics: CBC, Sodium, Potassium, Creatinine, SGPT, CBG, FBS, Lipid Profile, 12
lead ECG, Chest Xray (high AP sitting), urinalysis

Medications:
ASA 80 mg/tab, 1 tab OD after lunch
Atorvastatin 40 mg/tab, 1 tab ODHS
Citicoline 1g/tab, 1 tab BID
Omeprazole 40mg/tab, 1 tab OD 30 min before breakfast
Lactulose 30 cc ODHS, hold for BM >/= 2x/day

HISTORY TAKEN BY:

JIIC: Carandang, Marichelle D.
Co-JIIC: Alcantara, Diana Rose R.
Fernando, Katerina Mae F.
Leocadio, Mark Roldan, M.