Examination
MEDICAL HISTORY
PA - healthy until recently, not treated for anything, doesn't visit doctors much, coughs occasionally, recently has toothache
FamA - father died of MI at 71, mother is being treated for rheumatoid arthritis
FarmA - desloratadine 5 mg 1-0-0
Abuse - no smoking, alcohol once a week, negates drugs
AA - dust, pollen, mites
WA - cashier
SA - lives in an apartment with her husband
GA - 2 deliveries without complications, menstrual periods regularly
Physiological functions – Patient voids without dysuria, sometimes the urine was pink. Stool is regular, formed, of normal color, without blood. Dietary intake is adequate. No unintentional weight loss.
STATUS PRAESENS
Conscious, apathetic, tries to cooperate, speech understanding does not appear significantly impaired, but verbal speech is poor, not fluent, poor production of some words. Febrile, ameningeal, increased respiratory and heart rate, on initial neurological examination there is a drooping right angle and mild weakening of right upper limb, petechiae in oral cavity, carious dentition, lymph nodes not enlarged, chest, abdomen without obvious pathologies.
