January 25, 2017 Source of referral: Dr.

Fajardo
History taken by: Deevon M. Cariaga Informant: Marian Vacaro, 40, wife
Percent reliability: 90%

IDENTIFYING DATA: Edgar Vacaro, 44 years old, male, married, Filipino, tricycle driver,
Catholic, born in Jamindan, Capiz, on October 28, 1972, presently residing at Batasan Hills,
Quezon City, admitted at FEU-NRMF Medical Center on January 12, 2017.

CHIEF COMPLAINT
Disorientation and slurred speech

HISTORY OF PRESENT ILLNESS:

The present illness started 5 months PTA he had an onset of fever with temperature of
39C, chills, body weakness, watery stools, frequency of urination and polyphagia. No
consultation was made. Took Paracetamol (Biogesic) 500mg which did not afford any relief.
4 months PTA, consultation was made at Holy Spirit Clinic. CBC and Blood
Chemistry was done with a result of decreased hemoglobin and high glucose levels. Fecalysis
was also done and parasites were seen. Diagnosed with Diabetes. Medications given are
Metformin twice a day and Ferrous sulfate once daily. Persistence of body weakness, joint pain.
With no fever, no diarrhea until December.
3 weeks PTA, walk-in checkup at FEU-NRMF with Dr. Fajardo. Blood Chemistry was
done with a result of all normal except decreased hemoglobin. Wife decided to admit the patient
due to recommendation of transfusion of 3 bags of blood. The patient was admitted for 4 days.
Take home medications given to the patient are Gliclazide (Diamicron), Atorvastatin,
Gabapentin, Vit B1, B6, B2 (Neurobion) once daily, Clopidogrel, Febuxostat which afforded
relief.
2 weeks PTA, He woke up at 4am saying disconnected words but clearly spoken, then at
9:00 am sudden episode of slurred speech and disorientation.
1 week PTA, patient presented with fever. Took Biogesic (Paracetamol) 500mg which
relieved the patients symptoms. Blood Chemistry showed result from 131 to 228 Creatinine.
Blood sugar is normal.
On the day PTA, was done at Chinese General Hospital. Results were released same day.
It showed compression of vein with bleeding and swelling. The patient was advised to be
admitted by Dr. Fajardo.

PAST HEALTH HISTORY:

-The wife doesnt know if the husband have had certain childhood disease/s nor received
immunizations.
-1997: wife noticed marijuana in his pocket.
- 2007: confined at World City Hospital, surgery at the nape area because of benign cyst.
-2010: confined at East Avenue Medical Center because of vehicular accident.
-2016: Diagnosed with Diabetes.
-No known allergies.
FAMILY HISTORY:
Father: 60 y/o has asthma
Aunt: Diabetes

PERSONAL AND SOCIAL HISTORY:

Married for 20 years, wife is apparently well, he is a Tricycle driver.

Usually sleeps around 8 and wakes up 4am with shallow sleep. Skip meals during lunch due to
work but compensates it with heavy meals during dinner. Before diagnosed with diabetes hes
fond of eating beef with rice. A 17 pack-year smoker, stopped 3 years ago. Started drinking
alcohol when he was 14 yrs old, drinks everyday such as beer,rum, vodka and brandy and was a
heavy drinker but when he stopped smoking he reduced his drinking to 1 bottle of beer a day.
Coffee intake: breakfast only, black coffee.Wife saw marijuana on husbands pocket 20 yrs ago.

REVIEW OF SYSTEMS:
Constitutional Symptoms:
(+) Body weakness
(-) fever
(-) chills
EYES, VISION
(+)Visual Changes
(+) Double Vision
(+) Blurring of Vision
RESPIRATORY
(+)Cough
(-)Shortness of breath
(-)Wheezing
MOUTH AND THROAT
(+) Toothache
GASTROINTESTINAL
(-)Abdominal pain
(-)Heartburn
(-)Bloody stool
GENITOURINARY
(-)Frequent urination
(-)Urgency
MUSCULOSKELETAL
(-)Joint pain
(-)Restricted motion
(-)Musculoskeletal pain
SKIN & INTEGUMENTARY
(-)Rashes
(-)Sores
(-)Blisters.
(-) Growths
PSYCHIATRIC
(-)Nervousness, anxiety
(-)Depression
ENDOCRINE
(+)Heat or cold intolerance
(-)Excessive thirst
HEMATOLOGIC/LYMPHATIC
(-)Abnormal bleeding
(-)Bleeding
ALL/IMMUN:
(-)Allergic reaction
NEURO
(+) Confusion

PHYSICAL EXAMINATION:

Assessment of the Head, Eyes, Ears, Throat and Neck (HEENT)

Head
Normocephalic

Scalp: no lesions, scaling, tenderness, and masses

face: symmetrical

Neck
Symmetrical, head position midline
Trachea in midline
Lymph nodes: no tenderness

EYES
External Ocular Structures
Eyebrows : No scaling or lesions
Eyelids/eyelashes: Eyelids meet together, evenly distributed
Skin without redness, discharge or lesions
Conjunctiva and sclera
Conjunctiva - normal color pink over lower lids, white over sclera
Sclera china white,PERRLA, Contralateral Pupil Constriction

Ear: Ears equal size, Skin intact, same color as face, intact, No Tenderness, No lesions, swelling,
drainage
Tympanic Membrane: no redness, swelling, discharge, foreign bodies, translucent with a pearly
gray color.Ear drum should be flat and intact
Inspection of Nose, Mouth and Throat

Eternal nose: Symmetric, midline, No inflammation, patent no tenderness

Nose:no lesions, swelling, symmetry, discharge
Mouth:no lesions, swelling, drainage,

Dental carries

Tongue: Pink and even Thin white coating. Ventral surface should be smooth, glistening,
showing veins.Saliva is present

Uvula:Soft palate and uvula rise in the midline (CN X)

Throat: no lesions

Tonsils: not enlarged

Abdomen:
Symmetrical;brown skin, no lesions and no scar; globular and the umbilicus is inverted; no
visible pulsations. No bulging flanks. No dilated blood vessels. No visible peristaltic waves and
no mass. Normoactive bowel sounds, no bruit heard over the epigastrium over the epigastrium,
and paraumbilical areas.

Liver span: 9cm at the level of the 3rd and 4th ICS. Splenic dullness over one ICS from the 9th
to 11th ICS. No presence of ascites. (-) Fluid wave, (-) Shifting dullness, (-) Kidney punch.
Abdominal wall is soft, no tenderness, no masses; liver, spleen, kidneys are not palpable.

Examination of the Neck:

Inspection:
Symmetry - symmetrical
Size - normal
Deformity, mass, swelling - none
How patient carries head: Upright (normal)
Range of Motion:
Flexion, Extension, Lateral Rotation, Lateral Flexion - all ROM within normal limits. However,
patient takes a long time before he can approximate the position
Palpation of Neck, Trachea, Lymph Nodes, Thyroid Gland - normal
Examination of Thorax and Lungs
Inspection: normal color, no lesions, no dilated blood vessels. Bony thirax is normal
Respi Rate: 12cpm
Timing: Normal
No Abnormalities
Palpation:
No tenderness
Normal lung expansion
Auscultation
Adventitious sounds - slight wheezes
Heart:

No neck distention. Carotid arteries pulsation: strong, regular, equal, and soft walls. Precordium:
flat. Apex beat: adynamic, not visible, but palpable; located at the 5th ICS 2cm medial to LMCL,
1cmx2cm. Systolic thrills felt over 2nd Right ICS, parasternal line. Regular rhythm, increased
intensity, no splitting of heart sounds. S3 and S4 not heard. (+) Murmur: heard best at apex,
radiating to 2nd ICS, parasternal line, systolic, Grade 4, blowing quality, low-pitched,
decrescendo

Peripheral Vascular System: Upper & Lower extremities are normal in size, symmetrical.
Brachial, radial, popliteal, and dorsalis pedis pulses have regular and equal pulsations, walls with
soft consistency. No chance to observe femoral pulse.

General Survey:
Level of consciousness: Impaired- drowsy
Orientation: irrelevant answers
Appearance: The patient looks older than his actual age
Appropriate and well-kempt
Attitude and Behavior: Cooperative
Speech and Language: slurring of speech
Memory Mood and Affect: Memory- irrelevant answers
Mood- dysphoric/sad
Affect- appropriate
Nutritional Status: Underweight
Gait and Posture: cannot be done with the patient
Body Built: Slender and tall
Signs of Distress: none
Vital Signs
Bp- 130/90
Cardiac Rate- 96beats/min
Pulse Rate- 96/min
Respiratory Rate- 12cycles/minute
Body Temperature- 35.6 degrees centigrade

THE NEUROLOGICAL EVALUATION

CEREBRAL FUNCTION
A. Assessment of GENERAL CEREBRAL FUNCTION
1. Level of Consciousness (GCS:13 E: 4 V: 3 M: 6)
2. General Behavior and Appearance
a. Appropriately groomed
b. Cooperative
c. Quiet
3. Intellectual Performance
a. Not oriented to time, place and person
b. Memory: not able to recall immediate, recent and remote memory
B. Assessment of SPECIFIC CEREBRAL FUNCTION
1. Language
a. Cannot talk spontaneously, repeat words but can comprehend verbal request
2. Intact Object recognition and Motor Integration
CRANIAL NERVES
Intact Cranial Nerves I-XI except Cranial Nerve XII; not able to protrude tongue
MOTOR FUNCTION
A. Muscle Tone: Normal Muscle Tone, continued resistance to passive movement.
B. Muscle Strength:
LUE: Grade 4
RUE: Grade 4
LLE: Grade 4
RLE: Grade 4
C. Reflexes
a. Superficial Reflexes: +Corneal, - Gag
b. Deep Tendon Reflexes:
2+Brachioradialis,
2+Biceps
2 +Triceps
2+Patellar
2+Ankle Jerk
D. Primitive Reflexes: none
E. Pathological Reflexes: none

SIGNS OF MENINGEAL IRRITATION

A. Nuchal Rigidity: none
B. Brudzinkis sign: none
C. Kernigs sign: none