Initial Evaluation

NAME: Eduardo Cantillo DATE OF I.E: December 12,2018

SEX: ♂ DATE OF Adm: September 28,2018
ADDRESS:8-D figuero St. Sawang, Calero,Cebu DATE OF REFERRAL: November 7,2018
DOB:March 31,1965 REFERRING MD: Unrecalled
NATIONALITY: Filipino PHYSIATRIST: Dr.Erich Canazares
RELIGION: Roman Catholic Dx. CVD infract c ® sided residuals
OCCUPATION: Warehouse worker Meds: Amlodepine 10mg & angiostatin to be
HANDEDNESS: ® taken every a.m. q.d. ; vitamins (name
CIVIL STATUS: Married unrecalled) taken p.m. q.d

/S/: (note: Some significant informations & dates was taken from significant other.)
C/C:Pt. complains of inability to move L UE & weakness on both L UE & LE.
HPI:Pt.’s current condition started on Sept. 28,2018, when he suddenly felt weakness of L UE &
began having difficulty speaking; was brought by wife to Dr. Jeffrey Lawas Clinic & was advice
& brought to Vicente Sotto Memorial Medical Center ( VSMMC) and was admitted for 9 days for
further evaluation. Undergone X-ray & CT-scan on sept. 29, 2018 & was Dx c CVD infract c R
residuals & on e same day felt sudden weakness of L LE. Undergone another CT- scan to
check if clot was dissolve by e meds. given (name of medicines unrecalled); was referred for
PTR p D/C in Vicente Sotto Memorial Medical Rehabilitation Center (VSMMR). On Nov.7, 2018
started PTR on VSMMR & was referred to San Nicolas Rehabilitation Center (SNRC) to con’t
PTR. Pt. was seen & started PTR on Dec.10,2018 in SNRC & is currently taking PTR sessions.
Social Hx: Pt. lives c with his wife, 1 son & 1 daughter that helps him do almost all aspects of
ADLs like changing clothes, bathing & toileting; has no cultural & religious belief that can hinder
pt.’s PTR.
Employment status: Pt. was a warehouse worker in Mandaue City; works on his feet and
carries sacks of products ≈ 10 hrs. from mon. to sat.
Living Environment: Pt. lives in a bungalow house c cemented floor; has a stairs c 5 steps & s
railing upon entering main door; pt sleeps & stays in e living room ≈ 3 steps from main door;
living room↔C.R ≈ 4 steps; living room ↔ dining room ≈ 5 steps.
General Health Status: Pt. rates health status as fair, s any major life changes that occur from
last year prior to e incident.
Social Health Habits:
Family Health Hx.
Patient’s Medical/Surgical Hx:
Medications:
Functional Status:
Pt’s Goal
/O/:
OI: