Patients Name: Z. d C. Address: 1301 bathurst st. north york Phone number: 354.

0174 Age: 44 years old Birthday: August 1, 1962 Birthplace: Manila Gender Female Marital Status: Married, with 10 children (4 male, 6 female) Race/ethnicity: Filipino, tagalog Occupation: housewife sells Avon Religious orientation: Roman Catholic Chief Complaint: Persistent pain in her right post auricular area Right hemiparesis, sudden onset Past medical history: (+) chickenpox (16 y/o), mumps (20y/o) and measles (+) hypertension, athsma Current medications: takes calcibloc or Neobloc when with high blood pressure takes dulcolax when constipated Social History: Cooks and watches TV during her leisure time, enjoys singing in videoke. Occasional alcoholic drinker and smokes 5-10 sticks a day.

Family Medical History: (+) hypertension-Paternal (+) bronchial athsma-Maternal

PHYSICAL ASSESSMENT: GCS of 15/15 HAIR: evenly distributed, thick dry and flaking HEAD Rounded, smooth contours with uniform consistency and no abrasions EYES: Pale conjunctiva, no discharges No edema or tenderness over the lacrimal gland, no tearing Transparent, shiny and smooth cornea, blinks when touched (intact trigeminal nerve) Pupil is black in color, approximately 4mm in diameter, round and smooth border Pupil is able to constrict, dilate and converge Both eyes coordinated, move in unison with parallel alignment EARS: Color is same as skin on the face Right ear is tender to touch, left ear pinna recoils after it is folded, cold to touch Normal voice tones are audible

 Patient says she hears ringing sound on her left ear NOSE: Symmetric and straight. Breathes with nasal flaring (difficulty) Not tender, no lesions Air movement is restricted when turned to one side. With clear and watery discharge ORAL MUCOSA, TEETH AND GUMS: Oral mucosa is dry With missing teeth, with dentures (partial) Brownish discoloration of enamel Gum color is pink with some dark patches Tongue in central position, smooth, lateral margins, no lesions Reddened, edematous tonsils, inflamed, no discharge NECK: Swelling right area Tilted to the right side Stiff head movement, limited range of motion, painful movement Unequal muscle strength Palpable and tender lymph nodes Thyroid (cant be assessed thoroughly) Ascends when swallowing SKIN Color varies from light to deep brown, no edema Some flat and raised nevi, no abrasions or other lesions

 Mild skin dryness, flaking at arms and lower legs Skin moves back slowly when pinched (+) dehydration NAILS With hangnails Delayed return of capillary refill CHEST AND THORAX Symmetric, spine vertically aligned Chest wall intact, no tenderness, no masses Breathing pattern: quiet and rhythmic

ABDOMEN With dry skin, flaking Flat abdominal contour No evidence of enlargement Audible bowel sounds No tenderness, relaxed abdomen No appetite. Can tolerate regular foods MUSKULOSKELETAL No atrophy Muscle tone is low Flaccid arms and legs (weak) Tenderness on the right knee joint Limited ROM Neurologic:

Oriented to 3 spheres (time, place, person) Clear and coherent verbal response Equal motor reponses bilaterally Weak grip on right hand Obeys commands, localizes pain, withdrawal, flexion, extension PERRLA 3mm

Integumentary: Moist diaphoretic, clammy skin Rashes on back and upper arms, contusions on abdomen Loose skin turgor Palpable mucous membranes

Respiratory: SOB with light activities Symmetrical chest excursion Wheezing lung sounds, sputum is thick and yellow O2 sat: 95%