Mga Suliranin Sa Irigasyon

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Initial Evaluation
Patient Name:OrlindaBalinog
Age: 62 y/o
Address: Laoag CITY
Civil Status: Married
Handedness: (R)
Occupation: Retired Secondary Teacher
Religion: Baptist
Referring Unit: Ranada Hospital
Referring Dr.: Dr. Ranada
Rehab Unit: Health and Wellness Haven Rehab Center
Rehab Dr.: Dr. Sheeree Ann Mina
Date of Consultation: Nov. 11, 2012
Date of Referral: Nov. 14, 2012
Date of IE: Nov. Nov. 14, 2012
Dx: S/P stroke, multiple Infarcts, (R) parietal lobe and white matter c (L) sided hemiplegia HPN, DM

HPI:
Present condition started 4 days PTIE; pt. was in their house when the pt. ate hamburger and French fries. The pt. suddenly felt weakness on her (L) side of the body and the pt. son noticed her slurry speech. Then the pt. son got bottled water wrapped with towel and he put it on the affected area of the pt. then after went to bed.

The next day the pt. decided for check-up with her daughter. The pt. undergone x-ray and CT scan (see ancillary procedure) and took meds (see present meds). The pt. stayed at the hospital for 3 days and while at the hospital, PT Rehab has already done. After the discharge, Dr. Ranada referred the pt. to have Physical Therapy program at the Heath and Wellness Haven Rehab Center under the supervision of Dr. Mina.

Ancillary Procedure:
Examination| Findings| Date|
X-ray| Unrecalled| Nov. 11, 2012|
CT scan| unrecalled| Nov. 11, 2012|

Present Meds:
Medication| Dosage| Indication|
Lozartan| tid| To treat high blood pressure|
Aspirin| tid| To relieve pain|

PMHx:

(+) HTN
(+) DM
(+) previous hospitalization (DM, Nov. 10, 2012)
(+) multiple infarcts

FMHx:

Condition| Maternal side| Paternal side|
DM| (-)| (-)|
HTN| (-)| (-)|
CVA| (-)| (-)|

PSEHx:
* Pt. has active lifestyle
* Non- cigarette smoker
* Non- alcohol beverage drinker
* Pt. lives with her husband and 5 children
* Lives in a 2 storey apartment with a winding stairs of 24 steps S:
C/c: “ Bigla nga kimmapsut jai makin kanninigid nga gudwa ti bagi na”
PT Translation: Pt. c/o weakness of (L) UE/LE
Pt’s Goal: To be able to return normal function.
O:
VS:
BP: a 130/70 mmHg
p 140/70 mmHg
Findings: ↑ in BP 2◦ Htn
Sig.: for baseline purposes
OI:
a/c/c
Mesomormph
(+) hemiparesis
(+) facial asymmetry
(+) drooling
(-) scar
(-) scaly skin
(-) clubbing of nails

Palpation
Normothermic on all exposed body parts
(-) tenderness
(-) edema

Neurologic Assessment:
Sensory Assessment
STD Used: Brush for light touch, thumb for pressure and pin for pain
Findings: 100% sensory intact on all exposed body parts
Sig.: Intact spinothalamic Tract

Deep Sensory Assessment:
Kinesthesia: Pt. is blindfolded and extremity or joint are move and asked the pt. to describe the movement. Proprioception: Pt. is blindfolded and extremity or joint are move and asked the pt. to describe the position of the move part at the end of the movement. Stereognosis: Ballpen, tape, and notebook are used. Pt. was asked to identify the following objects. Done 1 rep.

Findings: 100% sensory intact
Sig.: Intact Lat. Spinothalamic Tract

Tone Assessment:
Findings: Normothermic on (B) UE/LE
Sig.: Itact UMN

DTR:

RL

Legend:
0 - areflexia
+ - hyporeflexia
++ - normoreflexia
+++ - hyperreflexia
++++ - clonus

Legend:
0 - areflexia
+ - hyporeflexia
++ - normoreflexia
+++ - hyperreflexia
++++ - clonus

++ ++

++ ++
++...
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