GENERAL DATA

            This is the case of H.T.B., 67 years old, male, married, Roman Catholic, Filipino, a resident of Ajuy, Iloilo was born on August 29, 1947. He was admitted at Iloilo Doctor’s Hospital last August 15, 2015 at 12:00pm.

            The informant was the patient himself with 95 % reliability.

CHIEF COMPLAINT

            RADIATING BACK PAIN

HISTORY OF ILLNESS

Twelve days prior to admission, the patient felt a sudden onset of intermittent back pain located at the right upper quadrant that radiates towards the anterior side. The stabbing, prickling pain was graded 10/10. Episodes of pain last for 10 to 15 minutes. Back pain was accompanied by high- grade, intermittent fever, chills, itchiness of throat, difficulty of breathing, weakness, dizziness, vomiting, and loss of appetite.  There was also a reddish swelling at the site of pain. The swollen part was soft, fluid- filled and very painful when pressed.  The patient preferred to sleep in the right lateral decubitus position which compressed the swelling.  He would reportedly wake up in the middle of the night due to the pain. Paracetamol was taken during episodes of fever which provided temporary relief. Mefenamic acid was also taken but the pain was not relieved. The patient would cover the painful area with Gmelina (Gmelina arborea) and “Sarisa” (Muntingia calabura) leaves for an hour every night which gave temporary relief.

Eight days prior to admission, symptoms persisted. There was further enlargement in the swollen part and the pain intensified. The patient went to a district hospital in Barotac Viejo for a consultation. He was admitted in the said district hospital since there was no relief of symptoms after administration of unrecalled oral medications.

Four days prior to admission, the patient was discharged despite the persistence of the pain and swelling in his back. X ray examination was done and results reveal pleural effusion in the right lung, atheroscl aorta, hazy densities in the right lower lung, and obscured right cardiac border, right hemidiaphragm and costophrenic sulcus. He was advised to transfer to a hospital with sufficient equipment to drain the effusion in his lung.

Two days prior to admission, repeat x- ray examination was done and results reveal elevation of hemidiaphragms due to poor inspiratory effort, blunting of right costophrenic angle, cardiomegaly, atheroscl aorta, and pleural effusion in the right lung. The results were shown to a private physician who advised the patient for admission.

PAST MEDICAL HISTORY

The patient has no history of tuberculosis, asthma, bleeding disorders, convulsions, seizures, hypertension, and diabetes and claimed to be fully immunized. He has no known allergies to any food, medication or environmental allergens.

Patient has undergone appendectomy 30 years ago and no complications were noted.

FAMILY HISTORY

There is no history of diabetes, hypertension, asthma or any other notable heredito-familial disease from both the maternal and paternal sides of the family and the patient’s relatives are said to be in good health.

PERSONAL HISTORY

The patient works as a fisherman and would usually work from 5 am to 12 noon. On the days when he is not fishing, he would do carpentry jobs.  He has no dietary restrictions and would usually eat fish, vegetables, and rice. The patient usually drinks at least 3 liters of water a day. He is also a regular coffee drinker consuming 2 cups daily. The patient has been a regular alcoholic beverage drinker for 52 years. He used to drink 3 liters of beer with 5% alcohol but gradually lessened his intake as he aged. He is also a 52 pack years smoker. The patient usually gets 7 hours of sleep daily, turning in at 8 or 9 in the evening and waking up at 3 in the morning. The patient defecates and urinates regularly.

SOCIAL AND ENVIRONMENTAL HISTORY

The patient resides with his wife and his 2 children in a non-congested rural area in Ajuy, Iloilo. Their house is made of mixed materials and has 2 rooms. Their household water source is a nearby artesian well. Their drinking water is from a sealed tank that collects water from an electric water pump. Their comfort room is situated outside the main household and is flushed via pail system. They dispose their garbage by burning. They also have a pet dog and take care of livestock such as chickens.

The patient earns approximately P300 per day. His siblings and children pay for his medical expenses.