SILLIMAN UNIVERSITY MEDICAL SCHOOL
ADMITTING NOTES
Name: LENDIO, HANALIE Attending Physician: Dr.
Date and Time of Admission: 07/09/2024 Room Number:
GENERAL DATA:
This is case of H.L., a 47-year-old, female, maries, Born again REVIEW OF SYSTEMS
Christian, from Bagacay, Dumaguete, Negros Oriental who was ⮚ GENERAL: (-) weight loss, (-) night sweats, (-) sleep
admitted due to….. disturbance, (-) overall weakness, (-) fever, (-) chills, (-)
fatigue/malaise, (-) increased thirst.
CC: Headache ⮚ SKIN: (-) Itching, (-) Skin Color change, (-) Rash, (-)
Informant: Patient herself (95% reliability) dryness
⮚ HEAD and NECK: (+) Headache, (-) Neck stiffness, (-)
HISTORY OF PRESENT ILLNESS: lightheadedness, (-) Dizziness, (-) Goiter, (-) lumps
⮚ EYES: (-) Visual disturbances, (-) Red, Painful eyes, (-)
4 days PTA onset of slurring of speech, which resolved tearing, (-) Cataract/ Glaucoma
spontaneously. No associated extremity weakness and facial ⮚ EARS, NOSE, SINUSES, MOUTH, THROAT: (-) Sore
asymmetry. No medications taken, no consult was done, no throat, (-) nasal stuffiness, (-) nasal discharges, (-)
medications taken. nosebleed, (-) bleeding gums, (-) dry mouth, (-) tinnitus,
(-) earaches
ODA , at around 6:20 pm. Recurrence of Slurring of speech ⮚ RESPIRATORY: (-) Cough, (-) hemoptysis, (-) SOB, (-)
associated with occipital pulsating headache 4/10 and (+) BP chest tightness
180/100 mmHg, Thus admission. ⮚ CARDIOVASCULAR: (-) palpitations, (-) edema, (-)
dyspnea (w/ or w/out exertion), (-) orthopnea, (-) chest
PAST MEDICAL HISTORY: pain/discomfort
⮚ Past admissions: ⮚ GASTROINTESTINAL: (-) Vomiting, (-) nausea, (-)
o none Diarrhea, (-) Constipation, (-) Abdominal pain, (-) Loss of
⮚ Past surgeries: appetite,
o none ⮚ URINARY: (-) Hematuria, (-) Dysuria, (-) Oliguria, (-)
⮚ Comorbidities: Flank pain, (-) Suprapubic pain, (-) Nocturia
o A known Hypertensive ⮚ MUSCULOSKELETAL: (-) Weakness, (-) Cramps, (-)
o UBP - 120/80 mmHg Swelling, (-) Limitation in movement
o HBP - 180/100 mmHg ⮚ ENDOCRINE: (-) Polyuria, Polydipsia, Polyphagia, (-)
o Diabetes mellitus Cold/Heat intolerance
⮚ Maintenance Medications: WITH GOOD COMPLIANCE ⮚ NEUROLOGIC: (-) Seizures, (-) Loss of consciousness,
1. Metformin 500mg TID (-) Dizziness
2. Glimepiride 2 mg OD ⮚ HEMATOLOGIC: (-) Abnormal bleeding, (-) Poor wound
3. Enalapril 5 mg OD healing
⮚ Blood Transfusion: none
⮚ Food/Drug Allergy: None PHYSICAL EXAMINATION:
⮚ Immunizations: None
GENERAL SURVEY: Awake, alert, afebrile, coherent,
FAMILY HISTORY: ambulatory and NIRD
⮚ Maternal: HPN
⮚ Paternal: HPN . DM VITAL SIGNS:
BP: 187/99 mmHg
PERSONAL AND SOCIAL HISTORY: HR:103 bpm
⮚ Patient is a nonsmoker, a non alcoholic beverage 02: 100% at RA
drinker who denies history of illicit drug use. RR: 21 cpm
⮚ Diet: Unrestricted T: 36.6
⮚ Physical Activity Zumba
⮚ Vitamins/ Supplements: None
⮚ Occupation: Teacher
Anthropometrics:
Weight: 62 kg Motor
Height: 178 cm
BMI: 19.6
Skin: no pallor, no jaundice, no pruritus, no rash, no active Sensory
lesions, warn to touch, good skin turgor and mobility
HEENT: normocephalic, atraumatic, anicteric sclerae, pink
palpebral conjunctiva, nosunken eyeballs, PERRLA, no sinus
tenderness, ears with minimal cerumen, pearly white tympanic
membrane, moist lips and oral mucosa, no tonsillopharyngeal Reflexes:
congestion
Neck: supple, trachea midline, no cervical lymphadenopathies,
no distended neck vein, thyroid not palpable
C/L: symmetric with good expansion, equal tactile fremitus, (-)
retractions, (-) crackles, (-) inspiratory wheezing upper lobes
CVS: adynamic precordium, PMI at 5th left intercostal space Cerebellar: Well-coordinated movements by finger-to-nose test
midclavicular line, no heaves or thrills, regular heart rate and and heel-to-shin test, right upper and lower extremities; no
rhythm, distinct heart sound, no murmurs dysdiadochokinesia
Abdomen: flabby, normoactive bowel sounds, tympanitic on all Meningeal: (-) nuchal rigidity, (-) Kernig, (-) Brudzinski (-)
quadrants except over area of liver dullness, soft, no palpable Babinski
mass, nontender upon light and deep palpation
Primary Working Impression:
GUT: (-) KPS, bilateral 1. Acute Ischemic Stroke, RMCA
2. HCVD
Extremities: no gross deformity, no edema, CRT <2 seconds,
strong peripheral pulses, no limitations in the range of motion
Neurologic:
MSE: patient is conscious, coherent, oriented to time, place and
person
GCS 15 (E4V5M6)
Cranial Nerves
CN I - no anosmia (able to smell)
CN II – PERRLA, direct and consensual PLR (pupils 2mm,
equally reactive to light and accommodation)
CN V – facial sensations intact, (+) corneal reflex, intact muscles
of mastication
CN VII – good and symmetrical facial expressions
CN VIII - able to hear spoken voice test, both ears; Rinne Test
AC>BC
CN IX, - uvula at midline, able to swallow, (+) gag reflex
CN XI - able to turn head and shrug shoulders and turn head
against resistance, both sides
CN XII - (+) tongue slightly deviated to the right upon rest and
protrusion, no atrophy or fasciculations
