2. Name: Chavarria, Tomasa
Age: 71 years
Gender: Female
Marital Status: Widow
Occupation: Retired.
Race: Hispanic
Education: Second Grade
Language spoken: Bilingual; Spanish and
English
3. Source of history: patient and her records.
Present illness: Numbness and tingling
sensation in the left side of body and unable
to coordinate walk well for three days.
Admitted to inpatient Rehabilitation center.
Past health: Non smoker or non alcoholic
Type 2 diabetes Mellitus
Hypertension,
CVA 6 years ago.
Family History: Unknown, client unable to
remember.
note: the client's name has been
changed for privacy and
confidentiality purpose.
4. Birth Place: Reynosa, Mexico.
Immigrant since 1980.
Religion: Jehovah’s Witness( does not accept
blood products)
She has two sons and lives with one of her
sons in one story house in Mission, Texas.
Her son works extensive hours, she spends
many hours at home by herself.
She was independent ambulatory without
assistive device before current admission.
5. No known Allergies
Neurological: Alert oriented; time, person,
date, place, situation. Pleasant and
cooperative
Vitals signs: WNL
Skin: Status post fall at home; skin
discoloration dry Scabs to bilateral knees and
left foot. and small painless nodule over the
bridge of the nose. No fever or chills or Rash.
6. Mouth and throat: Difficult to swallow,
Dysarthria, Dystmetria
Continence bowel and bladder.
Difficulty opening right eye, gaze preference
to right eye, Hemianopia.
Other remaining systems: Within Normal
Range. No significant abnormality was found
on assessment.
Laboratory Finding: WNL
7. Decreased endurance, Left sided weakness,
impaired dynamic balance.
Left side Neglect, she tends not to see left
field, difficult to recognize movement and
difficulty in following commands given from
left side field.
Dysmetria and Dysarthria but able to speak
and comprehend.
8. Aspirin 81 mg PO daily
Lipitor 40 mg PO at bed time
Plavix 75 mg PO daily
Amaryl 4 mg PO twice a day
Glucophage 100 mg PO twice daily
Hemocyte plus 1 tab PO daily
Lovenox 40 mg subcutaneous daily
Diet: 1800 ADA Mechanical ground, thin
liquid.
9. During taking health history and physical
examination, some issues regarding her
condition and disease were discussed:
The importance of participating in her daily
exercise and her ADLS such as daily shower,
PT/OT activities to promote her
independency during stay in rehabilitation
center and at home.
10. Bladder and bowel Training: the importance
of regular toileting to prevent incontinence,
retention and bowel bladder accidents.
Aspiration Precaution: Sitting position and
Modified texture of diet.
Have assistance at all the time to prevent
fall/injuries.
Prevention of decubitus ulcers : Frequent
repositioning and avoid long time sitting in
wheel chair.
11. Her past history of Diabetes, stroke
hypertension might have contributed in
occurrence of her current stroke.
Discussed the importance of keeping her
blood pressure and blood sugar controlled.
The importance of following diet
modification, low salt, low fat, low cholesterol
diet, diabetic diet. Consultation with
physician, nurses and dietary specialist.
12. The importance of continuation of medication
prescribed by physician. In order to prevent
anemia( Jehovah's Witness) by diet and
vitamins supplements as prescribed.
Psychological support: discussed the benefits
of adopting a day by day approach and avoid
as much as possible engaging into the types
of thinking that can exacerbate her anxiety,
also discussed her successful therapy results
and the reasons to be optimistic in regard to
her progress.
13. Jarvis (2012).Physical examination & health
assessment (6th ed). St. Louis, Mo:
Elsevier/Saunders.
