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Date of Interview: July 10, 2015

General Data: ES, 44 years old, Male, Married, Farmer, Filipino, Roman Catholic ,
lives in barangay Caranas,Motiog, Samar

HISTORY OF PRESENT ILLNESS
NAME OF INCIDENT: Alleged fall
TIME OF INCIDENT: Around 6:00 o’clock in the morning
DATE OF INCIDENT: June 30, 2015
PLACE OF INCIDENT: In their Coconut farm in brgy Caranas, Motiong,
Samar

Patient was apparently well until 10 days prior to visit, he was doing his
routine daily work in coconut sapping; He went to their farm which is approximately
2 kilometers away from their home. Until after 20 minutes of stay in tree and when
he was about to tie the jar against the stalk, the knot slipped off his hands and
immediately grasped the other stalk to hold his balance. He fell off from a 12 feet
high coconut tree with his lower back. He then suddenly felt a blurring vision and
loss of consciousness approximately 2 minutes.
2 minutes later, he gained his consciousness with unbearable pain in the
lumbar area radiating to the lower extremities associated with numbness and
unbearable pain (with a scale of 10) .There were no other symptoms such as
vomiting and headache.
He then placed in flat firm surfaced wood and brought home. He was then
noticed to have a mass in the lumbar area at the level of L2-L3 measuring 5cm x2.5
described as reddish, non-movable and tender. There were no medications taken,
patient was more confined to bed.
9 days prior to visit, patient’s condition worsened, patient now complaint of
hypogastric distention and inability to void with aggravating tenderness over his
both lower extremities associated with numbness now with inability to move both
extremities. Still no medications taken, they sought consult to “tambalan” and did
manipulation on both lower extremities and lumbar area. There was no relief of
symptom noted. Patient then decided to seek consultation at Rural health Unit of
Motiong and eventually referred to Samar provincial Hospital for further evaluation
and management. He was then admitted, catheter was inserted with temporary

apparently well 2nd child male. grade 7. with reported range of motion to both extremities but more of the left leg. due to financial constraints. 5 days prior the visit (after 4days of hospital stay) he was then advised referral to higher center for further evaluation and management. 1 year old. farmer apparently well 1st child male.relief of symptoms and he underwent series of laboratories and diagnostic work up such as thoracolumbar X-ray which revealed normal thoracolumbar x-ray with no compression deformity. apparently well 5th child. 13 years old. female. now patient reported urge to defecate but still with inplace catether. opted to go home against medical advice with take home medication of multivitamins taken once daily. female. 15 years old. mumps and measles Surgical history:  There were no history of previous surgical operation/injuries FAMILY HISTORY        Wife 34 years old. PAST MEDICAL HISTORY    There were no previous history of hospitalizations There were no known allergies to food and drugs There were no history of previous blood transfusion Childhood Illnesses:  With history of chicken pox. 11 years old. apparently well 3rd child male. He was confined to bed with in place catheter. 4 years old. daycare. apparently well 6th child. grade 10. He can now move to his sides. and claimed of temporary relief of symptoms. They sought consultation to “manhihilot” twice a week. and able to sit for a few minutes with assistance. 7 years old. grade 5. male. apparently well . with colds (with no medication intake) 4rth child. Patient still claimed of tenderness at the lumbar area with numbness radiating to the lower extremities. grade 2.

Respiratory: No history of cough. no lumps. no sores. no masses. no flank pain. no easy bruising and bleeding tendency. Open dumping is the usual method of garbage disposal. farmer. No easy Fatigability Gastrointestinal: No loss of appetite. Endocrine: No neck mass enlargement. no excessive sweating. no diarrhea. They have an estimated net family income of 5. and no dry mouth. no burning pain. Source of drinking water supply from a communal source approximately 20 meters away from their house not treated prior to consumption. no sore throat. with history of body weakness. REVIEW OF SYSTEMS General Survey: No weight loss. no discharges. no nasal stuffiness. Hematologic: No bleeding gums.000 monthly mainly from farming and coconut sapping. no history of trauma. no dribbling. Musculoskeletal: no swelling. no constipation. no hematochezia Urinary: No dysuria. no pain. urinates every 3 hours to a yellow-colored urine at about 200 ml per voiding Genital: no itching. They do not have electric source. no lumps. he lives with his family in a house made from light materials _____(estimate size of the house)They do not own a WST facility. no incontinence.PSYCHOSOCIAL HISTORY SE. no headache and dizziness Eyes: No redness. no hematuria. with slight palmar pallor Head: No lesions. no earache. no blurring of vision Ears: No hearing loss. currently residing in Brgy Caranas. no stiffness. Motiong. no heat and cold intolerance . no deformities Neurologic: No paralysis. Samar. no color changes in hair. an elementary graduate. no sinus tenderness and no nose bleeding Mouth and Throat: No bleeding gums. 44 years old. no palpitations. no head injury. no tremors. Patient is a non-smoker and an occasional alcoholic beverage drinker. No difficulty of swallowing. with difficulty of breathing Cardiovascular: No chest pain. Roman Catholic. no fainting. no dryness. no history of seizures. Neck: No pain. No fever Skin: No rashes. no excessive tearing. no excessive thirst and hunger. no motor and sensory loss. they shared from their closest neighbor approximately 5 meters away from their house. Nose and sinuses: No colds. no abnormal discharge. no limitation of joint movements. no sore tongue.

Ears: Inspection: Symmetrical. no swelling . Nose: Inspection: Nasal septum at midline. no petechiae. soft. Palpation: no sinus tenderness. no nodules. No periorbital edema.4 °C BP: 100/70 mmHg Skin: Inspection: Fair complexion.5x2. afebrile. no dryness. fine. no redness. With black. mesomorph. Pinkish nasal mucosa.PHYSICAL EXAMINATION Patient was examined on his 10 days after hospitalization. no discharges. lying on his back with good eye contact. non-movable Head: Inspection: Symmetric.E was done on his 10 th day after the alleged incident. lying flat on his bed. responsive. no hypo/hyperpigmentation Palpation: Warm dry skin w/ good skin turgor (skin pinch goes back immediately). not cardiopulmonary distress General Survey: P. no exudates. No discharges. conscious coherent conversant. and with the following vital signs: Vital Signs: HR: 80 bpm RR: 19 cpm T°: 37. superior border of pinnae aligned with the eyes. no swelling. Palpation: No masses. with 2. Nails w/o clubbing or cyanosis.5cm mass the lumbar at the level of L3-L4. no masses. Pinkish nail beds w/ capillary refill of <1 sec. evenly distributed hair. No lice no nits. no ecchymoses. no lesions. no ptosis. Palpation: No tenderness. pinkish palpebral conjunctiva. Patient is male. coherent. No scalp lesion or dandruff. Nose bridge not deviated. Anicteric sclera. no edema. tender. Eyelashes are even and not scanty. no tenderness Eyes: Inspection: Symmetrical eyebrows with equally distributed hair. conscious. no jaundice.

regular. renal. Palpation: Supple. no lesions. Liver span is 5 cm R MCL and 4 cm at MSL Percussion: Tympanitic in all quadrants Auscultation: Normoactive bowel sounds (15/min). Buccal mucosa moist & pinkish. no deformities. no lesion. iliac and femoral arteries. fremitus equal in all lung fields not decreased. synchronous with PR. Palpation: PMI at left 5th ICS MCL. No murmurs. bruits. no masses noted. no tenderness. no crackles. Tactile Percussion: Resonant in all lung fields.Mouth and Throat: Inspection: Pinkish lips. no wheeze. without retractions. no lumps. RR at 19 cpm. no thrills Auscultation: HR is 80 bpm. Symmetric chest expansion. urge to defecate . Palpation: No swelling. Abdomen: Inspection: Flat with inverted umbilicus. Genitourinary: grossly male. Tongue at midline. with attached catether attached to urobag draining 200cc yellow colored urine. no bruits in aortic. Liver edge not palpable. No scars or visible pulsation. No heaves. No bleeding gums. symmetrical and soft. Spleen & kidneys not palpable. Auscultation: Bronchovesicular breath sounds in all lung fields. or abnormal heart sounds. No masses noted Chest & Lungs: Inspection: Symmetric with equal bilateral expansion. trachea at midline. Palpation: no tenderness. not labored. Neck vein not engorged. adynamic precordium. no rhonchi Cardiovascular: Inspection: Carotid pulse full. Carotid pulse full. Tonsils not inflamed Neck: Inspection: Symmetrical. Uvula at midline.

No involuntary movements. without deviation. Gross hearing intact IX. XII . place. reactive to light and accommodation.uvula at midline. Patient understands simple questions and commands with no difficulty in answering. strength 5/5 and left lower extremities. VII . III. No muscle atrophy. good tone.no costovertebral angle tenderness Musculoskeletal: Inspection: Symmetrical upper and lower extremities. alert and oriented to person. able to push buccal wall against applied force.performs shoulder shrug bilaterally. Incomplete range of motion on both lower extremities Palpation: No tenderness.Tongue protrudes midline. no kyphosis. peripheral pulses are full and synchronous with HR Neurologic: Mental Status: Patient is conscious. (+) gag reflex XI .Back & Spine: Inspection: no lateral spine deviation. VIII .can hear both usual conversation and whisper. while 3/5 on the lower right extremity . No fasciculation. equally round. Turns head against resistance. nonmovableno.with well contracted temporalis and masseter muscle upon clenching teeth. both pupils 2-3mm. and time. no masses. (-) flattening of nasolabial fold. with symmetrical pharyngeal elevation. no tremor. lump at the lumbar area Palpation: with 2. X .5 cm mass at the level of L3-L4. VI – full EOM without nystagmus. no lordosis.face is symmetric. (+) convergence V . Closes both eyes tightly.5x2. awake. IV. Cranial nerves: I – No anosmia II – Visual acuity good. His remote and recent memory is intact. Motor: No atrophy in all major muscle groups. without atrophy. tender.

pinprick. pinprick.3/5 5/5 Cerebellar function: Patient can sit without assistance. Able to do rapid alternating movements. Decrease sensation on posterior 2/3 of both lower extremities. position sense and vibratory sensation intact in extremities Sensory: Light touch. can do heel to shin test Sensory: Light touch. able to perform finger to nose test. Deep Tendon Reflexes Right Left Achilles Patellar Biceps Triceps Brachioradialis 1+ 0+ 1+ 1+ 2+ 2+ 2+ 2+ 2+ Pathologic Reflexes: (-) ankle clonus 2+ . position sense and vibratory sensation intact on both upper extree to localize pain on the anterior 2/3 of both lower extremities.

(-) Babinski reflex Meningeals (-) brudzinki’s sign (-) kernig’s sign (-) nucchal rigidity Autonomic No bladder and bowel incontinence. . No excessive sweating.