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Assessment A. Biographical Data

Mr. L is a 61-year-old man from Tagum City who presented with headaches, dizziness, blurry vision, and body pain. He has a history of diabetes mellitus and was previously hospitalized for 3 days in 2008 with similar symptoms. He smokes and drinks alcohol occasionally. A physical exam revealed signs consistent with ischemic stroke. His medical history, family history of hypertension and stroke, lifestyle factors, and physical exam findings suggest he suffered an ischemic stroke likely due to risk factors like diabetes, smoking, and alcohol use. Close monitoring and lifestyle modifications were recommended for his recovery and prevention of future strokes.

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Roxanne Ganayo Claver
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46 views

Assessment A. Biographical Data

Mr. L is a 61-year-old man from Tagum City who presented with headaches, dizziness, blurry vision, and body pain. He has a history of diabetes mellitus and was previously hospitalized for 3 days in 2008 with similar symptoms. He smokes and drinks alcohol occasionally. A physical exam revealed signs consistent with ischemic stroke. His medical history, family history of hypertension and stroke, lifestyle factors, and physical exam findings suggest he suffered an ischemic stroke likely due to risk factors like diabetes, smoking, and alcohol use. Close monitoring and lifestyle modifications were recommended for his recovery and prevention of future strokes.

Uploaded by

Roxanne Ganayo Claver
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ASSESSMENT A.

Biographical Data

Name: Age: Address: Birthdate: Birthplace: Religion: Ethnicity: Marital Status: Occupation: Source of Interview:

Mr. L 61 years old Purok Sunshine, Visayan Village, Tagum City February 17, 1952 Compostela Valley Province Roman Catholic Bisaya Married Self-employed Client

B. Chief Complaint Mr. L was complaining of headache, dizziness, blurry vision and body pain. C. History of Present Illness While on the work, Mr. L has been experiencing body pain, headache and blurry vision followed by dizziness. Mr. L was brought to the hospital accompanied by his wife and was admitted there for three days last 2008. Other than that, Patient L was diagnosed of Diabetes Mellitus last 2005 when he had his check-up and Anxin and Gibenclamide. D. History of Past Illness Mr. L had experienced childhood symptoms such as fever, cough and colds. He has no allergies to foods or in dust as what she stated. About her immunizations, he stated that he was not sure about it if he had completed it. Mr. L usually takes over-thecounter drugs when having those symptoms as self-medication.

E. Personal, Family and Socio-economic History Personal History Mr. L was born in Comval Province on February 17, 1952. He was 61 years old, a Filipino citizen, married and has 5 children. He lives with his family and currently residing at Purok Dahlia, Visayan Village, Tagum City. He was admitted at the hospital last 2008 with a chief complaint of headache, dizziness, body pain and blurry vision. He was discharged three days after admission. Family History Mr. Ls grandparents on both sides were already died. Mr. Ls father had died due to hypertensive while his mother is alive and well. Also, one of his relatives on fathers side had her cerebrovascular accident that was bedridden for almost 5 years and other than these, there were no reported illnesses within his family and relatives. Mr. L was the third child in their family with 2 sisters and 2 brothers but their youngest died; the rest of them were all alive and well. Socio-economic History Mr. L is only a high school graduate and never proceeds to college. He had his small business which is a General Merchandise. Mr. Ls family source of income was his small small business which gains an estimated of Php. 400.00 per day and the income of his child who is working abroad. He and his family were baptized as Roman Catholics. They regularly attend Sunday masses and novenas together. With minor symptoms such as fever, cough and colds, self-medication is applied. Although they seek the advice of their physician, they also believe in albularyo and manhihilot. F. Nutritional History Mr. L usually eats meals three times a day since they can sustain and provide their needs. According to Mr. L, they usually have their stack of food such as fish and pork and only sometimes eat vegetables. According to Mr. L, he smokes and drinks alcoholic beverages during occasion or events that even until now Mr. L still drinks and

smokes but rarely and stated that he couldnt stop taking it. The source of their water is through delivery from dumoy water station.

FAMILY GENOGRAM Paternal Side


Narciso Elisa

Maternal Side
Simo Wennie

Nitoy

Noli

Luz

Lucy

Joy

Bolina

Bong

Totong

Don

Ramon

Nida

Mr. L

Mario

Rissa

LEGEND
Male Female

Hypertension Alive and well Deceased

Stroke

CONCLUSION On the gathered data and information together, our patient has Ischemic Stroke is characterized by the sudden loss of blood circulation to an area of the brain, resulting in a corresponding loss of neurologic function. On the data of our case study, patient's diagnosis was given emphasis and with these, there is a need to monitor clients condition in terms of signs and symptoms of this disease. In line with this, we have assessed the patient from headto-toe. The signs and symptoms of this disease should be monitored as well as the degree and severity of pain so as to collectively intervene to stabilize the patient. Additionally, the considerations of carrying out the prescriptive orders of medicine are also given importance. However, the progress and fast recovery of the patient depends on the cause and severity of the condition, therefore modifications in activities, exercise, and watching his diet was also advised to the patient.

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