Physical Examination and Review of System of Patient with Cerebrovascular Disorder, Infarct, Hypertension Ii
PHYSICAL EXAMINATION AND REVIEW OF SYSTEM
Date: September 19, 2011
Name: Mr. Ironman Diagnosis: T/C Cerebrovascular Disorder, Hpn II Vital Signs Temperature: 36.7o C Height: 5’6” Pulse: 62 bpm Weight:170 lbs. ( 77.27) Respiration: 22 cpm Observation: Received patient lying on bed, lethargic, oriented to person, place, Blood Pressure:160/110 mmHg and time, with #1 PNSS 1L regulated @ KVO rate,hooked @ Left hand, with 950 cc left, infusing well. Patient with facial asymmetry, slurring of speech,
|General |Received patient lying on bed, lethargic, oriented to person, place, and time, with #1 PNSS 1L regulated @ KVO rate,hooked @ Left hand, with 950 cc left, infusing well. Patient with R face sagging and facial |
| |asymmetry, slurring of speech, hyperactive and brisky extension of the arms; redness of the eyes also noted; Skin color is brown, |
|HEENT |HEAD: Normocephalic, black hair, sagging @ R side of the face, facial asymmetry, paresthesia at R half of the face and head, slurring of speech, decrease facial sensation @ R side, no lesions, no scars, EYES:|
| |PERRLA; R eye cannot adduct, and slow movement, diminished papillary constriction; pink conjunctiva, diminished corneal reflex, diplopia with both eyes open, normal vision with one eye, R eye slightly |
| |retracted, EARS: decreased hearing acuity @ R ear, no discharge, skin color same as face, symmetric, pinna proportional to head, NOSE: Patent, no discharge, symmetric, THROAT: diminished gag reflex , |
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Date: September 19, 2011
Name: Mr. Ironman Diagnosis: T/C Cerebrovascular Disorder, Hpn II Vital Signs Temperature: 36.7o C Height: 5’6” Pulse: 62 bpm Weight:170 lbs. ( 77.27) Respiration: 22 cpm Observation: Received patient lying on bed, lethargic, oriented to person, place, Blood Pressure:160/110 mmHg and time, with #1 PNSS 1L regulated @ KVO rate,hooked @ Left hand, with 950 cc left, infusing well. Patient with facial asymmetry, slurring of speech,
|General |Received patient lying on bed, lethargic, oriented to person, place, and time, with #1 PNSS 1L regulated @ KVO rate,hooked @ Left hand, with 950 cc left, infusing well. Patient with R face sagging and facial |
| |asymmetry, slurring of speech, hyperactive and brisky extension of the arms; redness of the eyes also noted; Skin color is brown, |
|HEENT |HEAD: Normocephalic, black hair, sagging @ R side of the face, facial asymmetry, paresthesia at R half of the face and head, slurring of speech, decrease facial sensation @ R side, no lesions, no scars, EYES:|
| |PERRLA; R eye cannot adduct, and slow movement, diminished papillary constriction; pink conjunctiva, diminished corneal reflex, diplopia with both eyes open, normal vision with one eye, R eye slightly |
| |retracted, EARS: decreased hearing acuity @ R ear, no discharge, skin color same as face, symmetric, pinna proportional to head, NOSE: Patent, no discharge, symmetric, THROAT: diminished gag reflex , |
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