NOTICE TO ARBITR Rlvale: uch Wate yah Of « O13S- aa T-1€-23 DATE: ‘TO: (NAME) + (ol phrty upon whom the Wotice is fade) (ADDRESS) m ; j ih (TELEPHONE) _&YD-"Isyp | GGE~Totd _ xy Ea: sae mpl Ph Pursuant to the arbitration clause of our existing Collective Bargaining Agreement, copy attached, the undersigned party decided to submit for voluntary arbitration the unresolved issues, I. SPECIFIC ISSUESIDISPUTE TO BE ARBITRATED (please provide particulars of the dispute) You are hereby notified that copies of our voluntary arbitration agreement as contained in our OBA and of this Notice to Arbitrate are filed with (name of voluntary arbitrator named in the CBA) and/or at the National Conciliation and Mediation Board-Regional Branch , with the request that it commence the arbitration proceedings or selection and appointment of voluntary arbitrator. NAME OF IMITATING PARTY { t ; ty if REPRESENTED BY ty Bend ty frrgay— posmonrme __(py(y Flaaso send fwo (2) copies of this Notice to Arbitrate to Name the Voluntary Arbitrator named in tha CBA and/or the NCMB Regional Branch, as provided under Section 3, Rule XIX, Department Order No. 40-03, Send Original ‘copy of the Notice to Respondent.tg ase eee a CONTRACT OF EMPLOYMENT KNOW ALL MEN BY THESE PRESENTS ‘Tha Convact eres no vet fy and setae sae we oe ‘neenatesyearea eae he Seta Nave tage Nae o Vesna: Pas as evel Saualatnnlal ses Tone wirNesseTH ‘That re seat ena be enpsoyed om Doar sae me okowng we aed constons Vi Deatee Comat Mteisinore Les 12 Panton Fimo thea FE 1 Bene Meany Seay 50th 1 nou of on, sae 1 cvenee ren 16 Yeceon tame Rey 500 ta 17 Pomorie ‘owe Pip 18 Calecie Gagaang Agee any OF AASHORWAE “The tems ana consitorw accoraanon wan ne Gevarng Bou Rasoubon Mo 08 and Memarancim Cxcvat No 10 b+ See 10 and enaon coca Neb Seen of 2520 Compare wn P2018 Aranarat te Mat PRSe Santen 2000 aka be ety ane ae vere > Any ateraone a cnarges any oa of hin Conrac shal be evahuned verted pocenaad and aporoved by te Phir “Stereeat Emeyne™ nevenatato" (POEA, Upon approve, ese al be Seemed a raegal bat of be Stance [onneats Condens Gacerang ne Umgoyment al Fmone Seaaren On-Board Ocean Gong Vetsels |< Vesa fh em a contort of ha Carct PA apres nase al be pour fo cpinay Acton ihe omega IN WATNESS WIMEREOE a partes hace hares sat te nanan ona © ayo Onmwraw 2028 a Sane ° 4 i ‘erties and word by Be POEA© ALM. BURIGSAY LAW OFFICE & ASSOCIATES February 08, 2023 ‘TSM MARITIME SERVICES (PHILS) INC GF,3F(LW) & 4F (RW-PORTION),1747 BLG AND 3/F (PORTI PALANAN, MAKATI ARTEMIO V SERAFICO President RE: SEAFARER ANI ELIO DI Dear SERAFICO: This pertains to the disability case of the above-named seafarer who was medically repatriated due to colon cancer adversely affecting his ability to work efficiently. He underwent series of medical treatment with the company doctor. However, despite such medical treatment, he remains incapacitated until today. After his medication was stopped by the company doctor, he consulted an independent medical expert and was found to be still suffering from the said colon cancer and declared the seafarer to be totally and permanently UNFIT to resume his work as a seaman. ‘A copy of the Second Medical Report is hereto attached. As a result, thereof, the seafarer is claiming total and permanent disability benefits in accordance with the law and his CBA. He further demands that he be referred to a third doctor to confirm his present disability. Please be guided accordingly. ILD M. BURIGSAY ae Room 310, Trinity Building, T-M. Kalaw Avenue, Ermita, Manila Tel. No. (632)-5644900 ¢ Email: amburigsaylaw@gmail.comam orscsay, ESRWILLIE N. SALUDARES, MD, FPCS, FPSGS, MPA General and Cancer Surgery Room 5 Mezzanine Floor, East Avenue Medical Center East Avenue, Quezon City Tel. No.: (02) 89297196 January 30, 2023 ‘Andreo T. Evangelio a 64 years old, male, married from Batangas was referred for evaluation. History revealed the following: April 2022 ~ Patient complained of painful micturition and occasional hypogastric pain, ‘May 2022 ~ Pain and hypogastric pain/discomfort persisted so he requested that he be allowed to seek consult off shore. His request was granted. He was brought to a hospital in Cape Town where several workups were performed, Abdominal CT Scan was suggestive of colon malignancy. Patient was sent home to the Philippines and was referred to a specialist at Manila Doctors Hospital. Extensive workup was done which confirmed the findings at Cape Town. CT Scan revealed a colonic mass with signs of metastasis. June 2022 — Patient complained of frequent abdominal pain with associated episodes of loose bowel movement. Abdominal distention was also noted. {A diagnosis of intestinal obstruction was made so he underwent laparotomy. Findings on laparotomy are the following: Complete Intestinal Obstruction due to Ascending Colon Tumor. A. diverting ileostomy was performed. July 2022 - Patient was reopened and drainage of intraperitoneal abscess was performed. ‘August 2022 ~ Debridement of ileostomy wound was performed. Was sent home on the last week of ‘August. Further management was done on an outpatient basis. Chemotherapy was advised, At present, patient still complains of weakness and pain on the ileostomy site. Diagnosis: Well Differentiated Colon Adenocarcinoma with Omental and Liver Metastasis, /P Exploratory Lapaparotomy and Diverting lleostomy Purulent Peritonitis due to Ruptured Viscus $/P Evacuation and Lavage /P Wound DebridementDiscussion/Recommendation: Colon cancer is a type of cancer that starts in the large intestine. This condition usually affects older patients though it can appear at an earlier age. Symptoms may be vague at the onset like on and off abdominal pain and weight loss. Consistent symptoms in patients are: change in bowel habits including diarrhea alternating with constipation, rectal bleeding, persistent colicky abdominal pain, ‘weakness/fatigue and unexplained weight loss. The presence of tumor outside the colon signifies metastatic disease. Treatment in the initial stages is surgical followed with chemotherapy and/or radiotherapy. ‘Our patient already has metastatic colon cancer which means prognosis is already poor. Progression of disease is expected. The presence of an ileostomy which is very difficult to maintain will greatly hamper is physical activity. Patient is no longer fit to work in a sea vessel in any capacity. to . Vail lie N. Salidares, MD License No.: 63616 PTR: 4056549t AND EO T. EVANGELLO EN, 20>>>>>>>>>>>>>>8e1c062NS bososstHadaroysyoLe 2>>>>>>>>>>>>>>>>>>>>903NNVD>017 BONVARTHa>d Tere06o l's06 euuewrninun 03 Uo Bo) ase un op aunyeuss ALOHLAY Awusnan SNOLIVSINNWOD® ® © A.M. BURIGSAY LAW OFFICE & ASSOCIATES JANUARY 19, 2023 ATTY. EMMANUEL PARTIDO ASSOCIATED MARINE OFFICERS SEAMEN’S UNION OF THE PHILIPPINES Intramuros, Manila RE: CLAIM FOR T SEAFARER: ANDREO T. EVANGELIO COMPANY: TSM MARITIME SERVICES (PHILS) INC. POSITION: ELECTRO-TECHNICAL OFFICER. VES! "YGNUS EMBARKATION: DECEMBER 31, 2021 DISEMBARKATION: MAY 12, 2022 Dear Sir: \ My client would like to avail of the Grievance Procedure laid out under the applicable IBF-AMOSUP/IMEC CBA for his claim for disability benefits. He suffered colon cancer while on board. Upon arrival in the Philippines, he was referred for treatment at MANILA DOCTORS HOSPITAL where he was afforded medical attention for several months. However, notwithstanding the treatment afforded to him he is still experiencing symptoms rendering him unfit to work and making his return to seafaring job uncertain, For this reason, my client expressly manifests his desire to claim total and permanent disability benefits in accordance with the applicable CBA of which the vessel CYGNUS is, covered. My client respectfully requests that a conference be called on February 2, 2023 precisely to thresh out or explore possibility of amicable settlement. Hoping for your immediate action on this matter. ctfully yours, WITH Ct A ZBURIGSAY ANDI ELIO Room 310, Trinity Building, T.M. Kalaw Avenue, Ermita, Manila Tel. No. (632)-5644900 # Email: amburigsaylaw2022@gmail.com© A.M. BURIGSAY LAW OFFICE & ASSOCIATES JANUARY 19, 2023 ATTY. EMMANUEL PARTIDO ASSOCIATED MARINE OFFICERS SEAMEN’S UNION OF THE PHILIPPINES Intramuros, Manila Re: REQUEST A COPY OF CBA Dear Sir, ‘The undersigned would like to request from your good office a copy of the CBA for the following Seafarer: SEAFARER: ANDREO T. EVANGELIO COMPANY: TSM MARITIME SERVICES (PHILS) INC. POSITION: ELECTRO-TECHNICAL OFFICER. VESSEL: CYGNUS: EMBARKATION: DECEMBER 31, 2021 DISEMBARKATION: MAY 12, 2022 Hope for your kind and prompt action on this matter. Respectfully yours, Room 310, Trinity Building T.M. Kalaw Avenue, Ermita, Manila Tel. No. (632)-5644900 e Email: amburigsaylaw2022@gmail.comaM BURIGSAY,, LAW OFFICE seer tent netae MALE eTrenS \THt0N OF Eihiact hoe) syeteee 79 are! in ier Whoosh Regular Trask your pedal at sais. Ibeexpress com Tale te our Care sapresent ative ncexprees.com (532) 8858-5999 1-500- 10-2585-889 “survey tbcexpress..come 5 ©} ALM. BURIGSAY LAW OFFICE & ASSOCIATES JANUARY 19, 2023 MR. ARTEMIO V SERAFICO ‘TSM MARITIME SERVICES (PHILS) INC. GF,3F(LW) & 4F (RW-PORTION),1747 BLG AND 3/F PORTI PALANAN, MAKATI RE: CLAIM FO) PERMANENT DISABILITY BENEFITS SEAFARER: ANDREO T. EVANGELIO COMPANY: TSM MARITIME SERVICES (PHILS) INC. POSITION: ELECTRO- TECHNICAL OFFICER. VESSEL: CYGNUS EMBARKATION: DECEMBER 31, 2021 DISEMBARKATION: MAY 12, 2022 Dear Sir: My client would like to avail of the Grievance Procedure laid out under the applicable IBF-AMOSUP/IMEC CBA for his claim for disability benefits. He suffered colon cancer while on board. Upon arrival in the Philippines, he was referred for treatment at MANILA DOCTORS HOSPITAL where he was afforded medical attention for several months. However, notwithstanding the treatment afforded to him he is still experiencing symptoms rendering him unfit to work and making his return to seafaring job uncertain. For this reason, my client expressly manifests his desire to claim total and permanent disability benefits in accordance with the applicable CBA of which the vessel CYGNUS is covered. My client respectfully requests that a conference be called on February 2, 2023 precisely to thresh out or explore possibility of amicable settlement. Hoping for your immediate action on this matter. Room 310, Trinity Building, T-M. Kalaw Avenue, Ermita, Manila Tel. No. (632)-5644900 ¢ Email: amburigsaylaw2022@gmail.comMARIE CHERRY LYNN < AMSON - FERNANDC ./.D., FPSMO Internal Medicine / Medical Oncology FELLOW DIPLOMATE: PHILIPPINE SOCIETY OF MEDICAL ONCOLOGY Member, American Society of Clinical Oncology MANILA DOCTORS HOSPITAL ST. LUKE'S MEDICAL CENTER Rm. 1116 Don Norberto Ty Medical Tower I! GLOBAL CITY 664 T.M, Kalaw, Manila Rm, 211 Medical Arts Building Tuesday / Thursday: 11:30. am- 2:30 pm 32nd Street Fort Bonifacio ‘Monday / Wednesday: 11:30 am - 12:30 pm Global City, Taguig City Tel. Nos.: 8-558-0888 loc. 4904 / 4905 Fr Sat: 200 pm -5:00 pm Tok No. 8-79-7700 00 7211 THN >3, lors Cell No.: 0918-912-0812 / Email Address: macherrylynn@yahoo.com Mahal elipat Vile inf wate lp Het rn Gancee Cy gle mak eae eae afk here ord fog Go PTR I>ESS Ors. Rosendorff, De Kock, Daya & Greeff (Inc) (20 Poe ute 1201 Shenae Bara Remar eg renee Occupational Health Practitioners ‘TO. WHOM IT MAY CONCERN: may ron sevevanes ANDREO TUMMAGA EVANGELIO IN CONSULTATION WITH A SPECIALIST SURGEON FT WAS RF THAT Mi EVANGELIO BE REP ASSOON 48 POSSHA YURTUER TREATMENT IN HIS HOME COUNTRY. THs WOULD AVOID PROLONGED STAY IN THE MOSPITALINCAPE TOWN ME ES PRESENTLY FIT TO BE REPATRIATED BY ATKDR K} GOLDBERG Suite 1611 BMH CAPE TOWN To DF. Gordon Greet Andieo Evangelo 163} 915722 ‘Dear Gordon many thaeks forthe referral Andre ist yrs cll and presents with right iia: fox pain and change in towel habit over the pst year. Of intrest sth Inc had 2 cholecystectomy a year as OVE He has got a mass palpable inthe right ac fossa SACT-scan’ lesion n the ascending colon with uirupertoncal mets. plus «large mot the iver ‘ks discussed with you be will need a mult disciplinary appoach with surgery and ‘Chemotherapy | thnk he would do beter i his home country Kind regardsDrs. Rosendorff, De Kock, Daya & Greeff (Inc) {00 THE ANNEXE, . ees ree net Haat, eset Capetown, 1901. = + 07.05.2022 Evangelio Ex Mv Cygnus. ‘The above seen on the 6” May complaining of increasingMARINE MEDICAL SERVICES a 9 NTMT2 Building 667 UN Ave. Ermita, Manila Prippnes 000 24/1 cP: 09057348600 05235324553, [VALID UNTIL Date:December 20, 2022 Mie name eae ‘ny: Patient’s Name: Andreo Evangelio ee: eco ECA Manning: visti Cy Adres MDH Molecular Rapid Antigen Test MD. (for any concern or question kindly call Marine Medical Services contact numbers) mull ree: marinemed pits net» Website: hp/iwww marnemediasevies att “et No, (632) AD 3656 »(62) 2523.53 +6) ADIOS (62) 823358 FORM 1! REFQM 852 (REV 1)cartstiann pernasd xamoriat soepita2 @Qsnare Room 1619, 18th Floor ‘Drs Dietrich, Voigt, Mia (nr DP Malan and Roa Bartholomew Diss Pi aT 001 CAPE Tow! Age + Sox 1 DOB + 64:M:1958-05-02, Aath/Po/Order No | MOT SUPPLIED Specimen o506suaoa.230 Duployer/inp No + MOT SuPRLIED Collection pate + 2022-05-06 17:05 Negaid Munber = MOT AVAILABLE L000 COUNT & PLE, EXT DIFF, U/B + CREAT REF RANGE COMET, eGPR {CKO-EPT) Specinen Types + Blood Primary 1CD10 Code (a) «276.9 Saba cold (sist aa 90s doe > Maenogiobin 23 ks - 16.5 gat S finenatoerst 0:40 aaa o.sa t/t S nei eee ee ety > cue Lok 3a se ala “5 White eel cone ane a ave ae sani > Neutrophils 2.0 2.83 2100 - 7.50 x1089/1 2 uymphacyees 1 anak aay Pala: aia sabeert > wonecyte 20.08 K 2.36 3.50 mio89/2 > sosinopnite Lot bias Paso sa089/t 2 Neutrophil bande are ok 389 9.90 - a.70 1089/1 > Mecamyelocytes Soom wb ‘alo0'~ 0.01 moeeyt: + Repost Continues on Page 2 +bile sama Roane eseaernt o Specines Collection Date Received Date Report Date 3 Platelet! coins 308 340) 2 ao sano ‘You sx09D COUNT CoNOERIT (SUPPLERD TP RELEVANT) varied nonocytonia, 16 secondary causes have beea ex: lide, ‘icthee Laveaeigation’ to rile oik poouible Ciod: 10 wdVined (Zncluding bone marrow biopsy) Signed out by De ceria Grieeel on 2022-05-07 11121100 Por consultation, contact a Saenatopethologiat - 427 21 596 3692 atigh, tntow, *HeCritically High, *LeCritically Low, #eDelta Checked ~ Fite ['} Phone Faeient ( ] Appointment [1] Prescription {1 Draw File (1alee sestensy ees scare neeneoa rh Yn Ma iia apo dab a TTT (Se = nama sosanaer ——) ‘MR ANDEEO EVANGELIO. 3001 CAPE Tom Age + Sex : DOD: 64:M-1950-05-01 auth/Po/Ordex Mo NOT SUPPLIED specimen oso6:snoseasu ‘mployer/enp No: NOT SUPPLIED ‘Tents Requested + BLOOD COUNT & PLT,EXT DIFF,U/E + CREAT,REP RANGE COOOIEIET, S-PoTassrom M4 36 3.5-5.1, mol/L, Siscomontoe dn! bs Se-108 amal/L > S-BICARBONATE 4 26.2, 22.0-20.0 mmol/, Sihatzow np hah : Ie Sas moti > S-OREA HY st 2.9-8.2 mol/l pemmotnnie waco pecan TENTS oat moi > CHD-HPI eGFR (ni/min/2.7392) 2 ay ‘Results for GFR should be interpreted’ ia’ conjliseeion with urine albunin creatinine ratio (ACR). e0FR may be tnrediable in pregnancy, the elderly, extrenes of ils6ie meas, acute renal impairment, aevere dehydration Refs WHE £/50z Guide! inen/ KEEGO 2049 Qvideline s+ Report Continues on Page : 2 +@ tsCare regi i Me Specimen Collection Date Received Dei Report Date 0506: enoacesu 2022-05-06 17:05 2022-05-06 17:07 2022-05-07 09.54 ~ BrocHmMrsTRY Yor conmultation, contact # chenical Pathologist - +27 21 596 3400 Maigh, Lstow, *HeCritically Migh, ‘LeCritically Low, faDelta Checked 1m rare cas0a, analytical interference may cause erroneous results Please inform pathologset if results and clinseal picture do not concur = File [] Phone Patient (|] Appointment (Prescription {1 Draw ile [1ae dlr | e@ ana aoe a a eT TT ME ANDREO EVANGELO 001 cape Tom age + Sex = DOB | 64:¥53958-05-01 ‘uth/20/Oxder Mo NOT SUPPLIED ‘Spectnen 506: Bx028130 Exployer/Eap No: NOT SUPPLIED Coliection Date + 2022-05-06 27:05 Weenia Munber NOT AVATIARLE Teste Requested + specimen Types + Blood Primary 1CD10 Code (sl: 276.9 ~ ENDOCRINOLOGY — SR6R. laa) 7 MeCN z 040 ie aL agit 282 Yor consultation, contact a chenical Pachoiogiat ~ +27 22 596 3400 Metigh, tetov, *eCricicaliy Migh, “LnCritically tow, #-Delea Checked ‘in rare cases, analytical interference may cause erronvous results Please inform pathologist it resuire and clinical picture do not concur. = File [') Phone Patient ( ] Appointment [] Prescription [] Draw File [ ]MARINE MEDICAL SERVICES, parRecember 16, 2022 FOR SSSIOWWA PURPOSE ONLY NOT VALID FOR MEDICO-LEGAL USE To Whom Dt May Concern, ‘Ths to certify that fas undergone medial /sugical evaluation bealment ot Marine Medioal Sewioes Mr. Andreo T. Evangelio f= May 12, 2022 b& Present dusty Well Differentiated Colon Adenocarcinoma with Omental and Liver Metastases; Purulent Peritonitis Secondary to Ruptured Viscus; 5/P Exploratory Laparotomy, Drainage of Abdominal Absess, Peritoneal Lavage, Bowel Decompression, Loop Tleostomy, JP Drain Insertion and Biopsy of OMental Nodule eostomy and Abdominal Wound Dehiscence $/P Debridement of lleostomy Wound and Abdominal Wounds; 5/P Chemotherapy. EstheyG. Go mal adres: mainemed@plts net » Website: htp/www marnemedicalervices et “elfen No. (62) £282 3666» (652) #2523353» (632 4282-3358 « (632) 8282-3366 FORM 13 REFQM352 (REV 1)Wa Republi of the Phitppines ‘SOCIAL SECURITY SYSTEM Secor 22015, SICKNESS NOTIFICATION I2-lo ‘CLAIM NO. RE-FILING CLAIM NO. LETTERS AND USE BLACK IIE ONLY. PARTI. TO BE FILLED OUT BY THE MEMBER, [55 NUMBER ]COMMON REFERENCE So pareronneas TFICATION NUMBER amy Ops }O124 119401918 100 OO 12 741 1013 8] ] 044] 4 S811 4 6191913101011 ee NG —— ayy Ue — pean Sa bite a CHIE” concinra_LualnTt Coe ctr rer FAL ex, Srniene _ lei cucherevcngeli(® yahoo eon 9 ar = TRE ORE 78 TONER a SEE GH THUMB RIGHT INDEX 7 TEGRESEE CORTICT ROMER PARTI. TO BE FLED OUT BY EMPLOYER, [SrrcoveR To KoMEER | [NAME OF EMPLOYERIREGISTERED BUSINESS NAME ENA ADORESS Me [BUSINESS ADDRESS — 6S TTT 7 TT PR PORE |S ARTOF SK LEAVE —[ROTRIEATION FORM WAS ENOTIFIGATION GATE] AGCIDENTISIGRRESS OCCURRED WME jmscorern fccemenur us ovomcorerfomceren |ChWorking Cin a Premises [JOn Vacaton PEL A ae Lip ella Clonee Clee,snsinn Cnt men T carily that the above Information are le and corect and that Te Teparied accdenUiness 1s Guy recorded in Te Employer's Logbook for EC Claim under page number ___ and entry number, OFFICAL DESIGHATION aE EMPLOYERIAUTHORIZED REPRESENTATIVE, PART Ill- MEDICAL CERTIFICATE (TO BE FILLED OUT BY THE ATTENDING PHYSICIAN) [BRIEF MEDICAL FISTORY AND PERTINENT FINDINGS _ATTERONG PHYSICIANS CERTFIORTION | cert hat have seen and examined above-named patient on 2022. and in my epron,corfneent including recuperation penod may last _2">S_ days. Lael om mney oncnoss: Will Diferentiatrd (olan flenocact nanan igs bien patina) (Firv0 wore #023 [FACE OF COMPIIIENT START OF CONNEMENT ae OF ROSATALGenindr aaah Cree orm UnAPrAne ree Manila Vectors Hosprtek PRRTED NAME AN ORATIRE EE MI EIT Pa, KOORESS OF NSCS CUNGROSATAL— POTEET TP Cone Manila Dockors [asp RECEIVED BY "MEMBE SERVICES SECTION) ~ JRECEIVED BY (FOR Mt TUATION SECTION) SOUTEOERTRE one “we _| soMTREORN REDE _—ooE Perforate Hi ‘SOCAL SECURITY SYSTEM ‘SICKNESS NOTIFICATION ACKNOWLEDGEMENT STUB. ANE OF MEMBER 0 SSNUMGERTRN mm ey yey eget JREcEeD ay ‘SIGNATURE OVER PRINTED RAWE, POSTONTINE DATE THE ‘SSS BRANCHTHis PORTION TO BE FILLED OUT BY SSS PERSONNE. PART V- SCREENING RESULTS jBER SERVICES SECTION JMEDICAL EVALUATION SECTION ng was done an results ae 2 folows: screening was done and results ar a fotows: C inerder 1D Inorter no signa of Employee C1 wan tangs, please soe remarks No sionatroof Employer Remar: Gi neccal Centicate not accomplished Remarks [SCREENED BY [SCREENED BY SORATORE OVER PRINTED WME “ATE _ "Te SGRATURE OVER PANTED AME aE Te [REGEIPT AND SCREENING (RE-FILED CLAIM) REMARKS. Ci cain accepts Gi caaim not acoptes (see remarks) RECEIVED ANO SCREENED BY SG DE DATE ene ERE ‘PART VI; MEDICAL EVALUATION “A. PHYSICAL EXAMINATION AND INTERVIEW, 1 RECOMMENDATION = lias Cl exwnson dct prev ror) Dias Deamon (nce previuseporre eroaners) wee wens) ny Tre Paar Trane Peay D Prevous approval CD Previous approve Ti rept contre Ty ont Cons) ‘Gaia ot Dacha) ‘Dae acs) Crenonc- © rerues (© e01005 rer Cremonc- © rermes 1000S rer a “Dar a a Ci revunneo- Cl rerunneo- ae ae a Dae Di oeneo. Doeneo- PORES CONE [EVALUATED BY [ENCODED AND FELEASED EY SGRATORE RANE =e i Tae ‘BATE INSTRUCTIONS 1) Fiat itor in oe (1) 29 2) Ray inate NA" 2 Nel Appeal” he resid tat ot spate 2) Phone aac ha poteaton othe Snes Boel Reinbursomant ptcaton 4), Atte your inal on a atrasonserasies ini rm. 5) We SS Number and name of member nae supper documents ‘omits ©) member camel ign, wens 1 geri shal be a flows uo) wate’ One (1) wens tbe empoyenuborad ‘eprevanatve ad thar one 1) xu be any pes, BOE ‘Sous arate soraties cn inate eset and ‘Sint mbes one prion provded Part. [ATTACHMENTISUPPORTING DOCUMENTS. oxronoes conamentaiess {aerate y, CG and ote aprons rents = Operating omic oor that wi support agnosie aca a ocd whi on stom Gariate of Note of Ske wave by OLE (erento Focus Centheste ot Nowacvarcenent of Pyment ram Emeoye occu acini 3 tyson in) = Poe Report ‘ON FING OF NOTIFICATION EscEnalst Members “To eel poate ft fing. Snes Netto (form mu be ‘tented to empoyer in fve (9) clencer onys afr sat of Sennen acest 1) catoaert is ina hp - dean fo gteston io (1) yar tromaneouschave 1) actneninyy coed wheat wrk or win compar premises Enonyer ie ous nti Far EC cats, setrentohry mut be recoded inthe company book ‘thn fw (9 cand ay am rakca wowed of ocaence of the ‘Stngeny, Fare Sos wit ran employer ay oy (0) peter Sfoetune sum equate reame bet tempore ees Foxman ‘Tos pana fr tng. enloys ay. REMINDER ‘Vera of tats may be made te S88 Wate ams goes of cont ou Cl Centar 020-8648 $80 817-7777MARINE MEDICAL SERVICES Centiata No, 1542 180 0001 December 16, 2022 Mr, Andreo T. Evangelio Patient complained of hypogastric and flank pains during urination on the last week of April 2022. This was accompanied by occasional incomplete bladder emptying and bulging on the right mid abdominal pain. He did not have change in bowel movement. He sought medical consult at a hospital in Cape Town, Aftiea on May 7, 2022. He also complained of upper abdominal pain, He was subsequently admitted. Work-ups including CT Sean were done. He was allegedly advised further testing for possible his intestinal problems. He was given medications. He was dischared on May 9, 2022. He was repatriated. He was referred to Marine Medical Services for further evaluation and management. Initial Impression (May 12, 2022) ~ Ascending Colon Tumor; To Consider Malignancy. Present Diagnosis (December 16, 2022) — Well Differentiated Colon Adenocarcinoma with Omental and Liver Metastases; Purulent Peritonitis Secondary to Ruptured Viscus; S/P Exploratory Laparotomy, Drainage of Abdominal Abscess, Peritoneal Lavage, Bowel Decompression, Loop Heostomy, JP Drain Insertion and Biopsy of OMental Nodule; Ileostomy and Abdominal Wound Dehiscence $/P Debridement of Tleostomy Wound and Abdominal Wounds; $/P Chemotherapy. ‘THIS CERTIFICATE IS BEING ISSUED FOR $8 PURPOSES ONLY. EsthefG. Go M.D. Senior Medical Coordinator Lie, No. 104236 E-mail address: marinemed@pldtds1.net + Website: http://www.marinemedicalservices.net ‘Telefax No. (632) 8282-3666 + (632) 8282-33-53 (632) 8282-3358 + (632) 8282-3368MARINE MEDICAL SERVICES inte: etober 2029 fo: BlextnrTeci SET Cyanine TSM Maritime Sess es Phify. ne xa Ctiees Aratreo T. Evangelion CERTIFICATE OF FINAL ASSESSMENT (NON-WOKK RELATION) Final Diagnosis: 6 Well Didicrentlated Calon Adenoeareinoma wi b Omental and Liver Metastases « Purulent Perituultls Secondary to Ruptured Viseus . ory Laparctunts. rainage of Atdomlnal Macess, Peritoneal Lavage, lowes avey Lecatiey, AP Dtnin Inaction and Tuopay of OMental Nedule oo Abdominal Waurel Dehisernce © 5/2 Dehrdernent of Tirostomy Wound and Abdaraina! Wounds © SP Chea Colon Adlenoeite roa ia « multtactotial disease caused by formation of an adenessa with poogrese to carcinoma sk factors incl high ft, lw fer die, oesity xeoking,sleuot intabe, farmly history a itary binl diseane. The patieat's Mies is nck works related. His crmental aod liser metastases vith purulent peritonitis is secondary to Ruptisres) Visens are related to fi Colon Adenocarcinoma. These ure also not work related, [ batnen- Blnmedy wed GoD Mane Cher_Lunn SommunFesnndo, MLD, Senin Medical Conelinatr GneokoRst nil address: mannemed: q platdstunet © Website. htip.z-\ we narinemned jets No, (632) M82 $046 # (652) KIND.IESS © (032) KIS2 pervises net 8282.33"“g (aD: MANILA DOCTORS HOSPITAL ay, MEDICAL ABSTRACT Parient ID: 2288818 PaTient: EVANGELIO, ANDREO ‘AGE GENDER civic STATUS 64 MALE MARRIED ‘Ritending Physiciant Dat Adria! Dat Diacharged: Date Transferred: DR. ROBERT LiMt 12612022 22/2022 NA ‘Chief Complaint ABDOMIMAL PAIN ‘Admitting Diagnosis: Discharge Diagnosie: ‘Complate Intestinal Obstruction secondary to Ascending Colon Tumor Compete intestinal Obstruction secondary to Ascending Colon Tumor, with urulentPertontis;leostomy Wound Dehisconce, Abdominal Wound Dehiscence, SIP Divertomy Loop leostomy for Coion Cancer, Exploratory Laparotomy, Drainage of ntraperioneal Abscess (07/28/2022), SIP Debridement of leostamy of Abdominal Wound (08/04/2022) Reasons for Admission For Surgical Management History of Present illness: ‘1 month PTA, patient had hypogastric paln usually when urin ence admission ing, No other signe and eymploms. CT scan was done and showed colonic mass with metastasis, In the Interim lll with RLQ pain, constipation, watery stools with particles. No voriing, No hematochezia, Weightloss frm 64 hg to 51 kg, Consult was done and was advised surge Corman deg args aE ‘SIP Laparoscopic Cholecystectomy (2018, Teal) an ee eer aaeete OAs [Reason for the Request for Copy of Medical Abstract (for iiradmitied patiendsy NA SSIS TOR ie | wa es i ‘Pertinent Signs and Symptoms on Admission (ek applicable boxes) aes Zc | Cl Aitered mental sensorium Ti diarhes Tivtematemesis CiPapeatdes DEC az 077-1 Ch abornal cath Townes Ciematua sen) owe | Crereie Donen Greens 1 oan rnfeGERTED i Chetecig gone Covepee Cima, (1 Set ode Chem ess Coyaute sends Diikccdometna Cheung en Depa Ctewerestemty ema CUgeney | even acon Creve Owens venting Cicortgton eqn tvnaton Coronas Chis Cheon Bnencace Ban fighter Quatant ClO sit) [Reerectoncne nescence) — FES Speny Renn | General Survey 1B Awake and Alert atered Sensor Page _/ of 2 ree BP: 120/60 HR: 66 | Height (em): 1803 Weight (ko): 81 RR 18 Temp: 36.8 Ti Essentaliynomat ——LiAbnornal Popilay —C) Caniear Tibiy mucous Membrane pe Reaction mphadenopatty Clete Score DiPale Conjunctvee C1 Sunken eyebalis i Sunken Fontanele Others: TB Essentaly normal CTAsymmetrcal chest L] Deceased breath L]Wheezes] ‘expansion Sounds (CHESTLUNGS Cltumpis overbressvs Ci} Raleslerackos! intercostal rblavicuar retraction ronchi Jothers: ‘Essen(aly normal ~[]Dieplaced Apex Beat CI Heave andlor ThilsL[Pevicardial Bulge ovs 1 ireguiar Rhythm Muted heart sounds) Murmur Others: Saal ssenlaly somal CJASomibl vty Ej Abdomen Tenemess Tiyperacive Bowel oun 25,3MANILA DOCTORS HOSPITAL others: Not Done [COURSE TN THE WAR EAR RSS TSS an OTS STS CHSC DT we SST wea oe ee LES Taboratory Imaging resulls alachod) Check Box [JM there are additonal sheets) ———— MEDICAL ABSTRACT Parent ID: ai 2288818 PATIEN' EVANGELIO, ANDREO ‘AGE GENDER ‘Civit Status 64 MALE MARRIED ‘ong Pata ais Aa Dale Ditharged aie Transferred Or ROBERT it eanzoee Saaanes na O)Palpable Mass(es) (CD Tympananitic ‘Dull ‘C1 Uterine contraction Abscmen t otnere “Eeeaany rama Cod Sadr aan —Cicarvear aiiaion —— LT Frasers oatromar | uae) Freer Bony other: Not Doe Essentially normal Ticiubbing Ti Cold dammy skin Ticyanosis / mottled skin CD Edemarswelling Didecreased mobility Pale naitbeds Poor skin turgor ere EM Cl Rashes/Petechial (Weak Pulses: Clothes Bi Essentially normal TiAbnonmal gait Tl Abnormal Position owes sbsea NEURO EXAM Abnormal Reflexies) C1Poor altered memory] Poor muscle Poor coordinat toresserah 316 | Cooter: : Tl Essentially Normal Dass DPus Hepith infos leial In DIGITAL RECTAL lenge Prosate — DHemonmoie “BEC Tegan — DATE DOCTOR'S ORDER AND ACTION. 0612612022 PATIENT WAS ADMITTED UNDER THE SEVICE OF DR. ROBERT LIM, PATIENTS HISTORY AND PHYSICAL EXAMINATION WERE REVIEWED FOR EXLAP, COLONIC SURGERYWITH LOWER BIOPSY ON JUNE 30, 2022. DEBT 220 PATIENT WAS SEEN STABLE. CONSENT WAS SECURED. IMAGING AND LABORATORIES WERE NOTED. MEDICATIONS WERE GIVEN. ADVISED REFERRAL TO PRN, PATIENT WAS DULY MONITORED ‘eaURO PATIENT UNDERWWENT CONTEMPLATED PROCEDURE AND TOLERATED IT WELL. PATIENT HAS GOOD PAIN CONTROL, NO NAUSEA AND FEBRILE EPISODES, OriOT DATO PATIENT WAS SEEN AWAKE, ALERT AND NOT IN CARDIORESPIRATORY DISTRESS. IMAGING AND LABORATORIES WERE ORDERED. PATIENT'S MANAGEMENT WERE CONTINUED. PATIENT WAS DULY MONITORED. ‘ormos-0ar2022 PATIENT WAS SEEN STABLE, MANAGEMENT WAS CONTINUED. WOUND CARE DONE AND DRESSING WAS (CHANGED, NGT MAY BE REMOVED, ENCOURANGED GENERAL LIQUIDS, PATIENT WAS DULY MONITORED. ‘ormoa-i2022 PATIENT'S ANTIBIOTICS WERE CONTINUED. MAINTAINED ADEQUATE PAIN CONTROL. SUGGESTED TO CONSUME TPN, PATIENT WAS REFERRED TO MEDICAL ONCOLOGY. PATIENT COLOSTOMY WERE MONITORED | rao PATIENT'S MANAGEMENT WAS CONTINUED. MEDICATIONS GIVEN, LABORATORIES WERE ORDERED. MAINTAINED ADEQUATE PAIN CONTROL. PATIENT WAS DULY MONITORED OTST PATIENT WAS MAINTAINED WITH ADEQUATE PAIN CONTROL. ANTIBIOTICS WERE REVIEWED AND ‘CONTINUED WITH THE CURRENT DIET, PATIENT HAS STABLE VITAL SIGNS. WOUND CARE DONE AND. DRESSING WAS CHAGED, LABORATORIES WERE ORDERED. PATIENT WAS FOR CHEMO 4 WEEKS AFTER POST OP. ‘o77i6 2072022 PATIENT'S MANAGEMENT WAS CONTINUED. ANTIBIOTICS WERE REVIEWED AND WERE CONTINUED. ‘COLOSTOMY BAG WAS MONITORED, MEDICATIONS GIVEN AND LABORATORIES WERE ORDERED. INPUT AND OUTPUT WERE MONITORED, ‘OVI 287202 PATIENT WAS SEEN STABLE WITH GOOD VITAL SIGNS, PATIENT IS WAMTING FOR CHEMO, NEDICATIONS WERE GIVEN AND LABORATORIES WERE ORDERED, PATIENT WAS DULY MONITORED OTe 26RORE PATIENT'S MANAGEMENT WAS CONTINUED. ANTIBIOTICS WERE REVIEWED AND WERE CONTINUED. COLOSTOMY BAG WAS MONITORED. MEDICATIONS GIVEN AND LABORATORIES WERE ORDERED, INPUT ‘AND OUTPUT WERE MONITORED. Orie Berea PATIENT WAS SEEN STABLE WITH GOOD VITAL SIGNS. PATIENT 1S WAITING FOR CHEMO. MEDICATIONS, WERE GIVEN AND LABORATORIES WERE ORDERED, PATIENT WAS DULY MONITORED i ‘O7BOSTRO } PATIENT'S MEDICATIONS WERE CONTINUED. OR SCHEDULE WAS CON PATIENT WAS SEEN STABLE WITH GOOD VITAL SIGNS. PATIENT IS FOR DEBRIDEMENT OF ILEOSTOMY WOUND ON AUGUST 4, 2022 PATIENT'S MANAGEMENT WERE CONTINUED AND WAS DULY MONITORED. IMED AND CONSENT WAS TAKEN, PATIENT WAS DULY MONITORED. our. Page 2 of 3 TaKae. (ap: MANILA DOCTORS HOSPITAL ery MEDICAL ABSTRACT PATIENT ID: 2288818 PATIENT: EVANGELIO, ANDREO Ae GENDER ‘Civic STATUS 64 MALE MARRIED. ‘itending Physta Date Aarited! Date Discharged: Date Transferred: DR: ROBERT LIM 6725/2022 8922/2022 NA | ] PATIENT UNDERWENT CONTEMPLATED PROCEDURE ANO TOLERATED IT WELL PATIENTS VITAL SIGN “Oars TSR Dare wou WAS MONITORED. MEDICATIONS WERE GIVEN AND LABORATORIES WERE ORDERED. DEEP EXERCISES WERE ADVISED. eT SROAZ PATIENT'S MANAGEMENTS WERE CONTINUED, PATIENT WAS GIVEN ENOXAPARIN, [ABORATORIES WERE ORDERED. PATIENT WAS PROVIDED ADEQUATE PAIN CONTROL. PATIENT WAS ENCOURAGED TO DO ANKLE PUMP EXERCISES, ‘arI0- T2202 PATIENT'S MANAGEMENT WAS CONTINUED. MEDICATIONS GIVEN, LABORATORIES WERE ORDERED. | MAINTAINED ADEQUATE PAIN CONTROL, PATIENT WAS DULY MONITORED PATIENT WAS SCHEDULED FOR CHEMOTHERAPY ON SEPT 18, 2022. PATIENT WAS SEEN WITH STABLE \VITAL SIGNS, PATIENT WAS DULY MONITORED. care Ter20e2 PATIENT WAS SEEN STABLE WITH GOOD VITAL SIGNS. PATIENT IS WAITING FOR CHEN, MEDICATIONS: WERE GIVEN AND LABORATORIES WERE ORDERED. PATIENT WAS DULY MONITORED area 272022 PATIENT WAS SEEN AWAKE, ALERT AND NOT IN CARDIORESPIRATORY DISTRESS. ADVISED MAY GO 1OME. PATIENT CLEARED FOR DISCHARGE, Deiza022 DISCHARGE INSTRUCTIONS AND TAKE HOME MEDICATIONS WERE GIVEN, PATIENT WAS DISCHARGED. Date Performed: ‘Surgical Procedure RVS Code (Aflach photocopy of OR technique): Divertomy Loop leostomy for Colon Cancer, Exploratory Laparotomy, Drainage of Invapertoneal Abscess & Debridement of leastomy af Abdominel Wound ‘07/28/2022 & 08/04/2022 Histopath Result: To Follow ‘OUTCOME OF TREATMENT: (CHECK ( ¥”) APPROPRIATE BOX CRecovereo OX) proven TION OF ATTEND! Ci Clcamca Cl Assconoeo CIHAMA = (De ©] Transrenneo CETTE I CERTIFY THAT THE ABOVE INFORMATION GIVEN IN THIS FORM, INCLUDING ALL ATTACHMENTS, ARE TRUE AND CORRECT: DR. ROBERT LiM/ DR. LOU ‘Signature over printed name ‘Aliending Healthcare Professional PRC. 53445 PTR: 7168606. 72022 Date Signed MARQUEZ Tate DATE CERTIFIED TRUE COPY OMR-02,3 Page @ of 3 anesitmdm (il) | | me awwecorsemiesso | f sa 08 MESA TA swe © MALE 05/2/18, Mayon, 1958 MALE (ae el}- MARINE MEDICAL SERVICES CONSENT TO ACCESS MEDICAL RECORDS “Aidieo 1 Ellul bits This is to authorize Marine Medical Services (MMS) to have access to all my medical records durling-rny confinement here at Manila Doctors Hospital. \ understand that Marine Medical Services will be'responsible for fling and collating all my records dlucing iy entire treatment as out-patient/in-patfent and will be borrowing my medical chart for documentation and Insurance purposes while | am admitted inthe hospital {the chart gets lost while with Marine Medical Services, | leave Manlla Doctors Hospltal free froin any responsibilities or Habillty. PRINTED NAME OF MMS STAFF PATIENT/RELATIVE Page 1 of 1Drs. Rosendorff, De Kock, Daya & Greeff (Inc) 12th Floor, Suite 1201 Tol: +27-21-424-2003 Christiaan Barnard Memorial Hospital Fax: +27-21-424-2023 Foreshore 8000 info@airseamed.co.za www.airseamed.co. [REGISTRATION NO. 2001/026950/21 PRACTICE NO. 0140000072489 Occupational Health Practitioners TO WHOM IT MAY CONCERN: 09 MAY 2022 MV CYGNUS ANDREO TUMBAGA EVANGELIO IN CONSULTATION WITH A SPECIALIST SURGEON IT WAS RECOMMENDED THAT MR EVANGELIO BE REPATRIATED AS SOON AS POSSIBLE FOR FURTHER TREATMENT IN HIS HOME COUNTRY. THIS WOULD AVOID A. PROLONGED STAY IN THE HOSPITAL IN CAPE TOWN. HE IS PRESENTLY FIT TO BE REPATRIATED BY AIR. Tea OFS aya & Greet oe aap oar By comer SH tt") * LEM Bien ser DR G GREEFF B22 ey DR’S ROSENDORFF & PARTNERS vnecrons [DR GRAHAM ROSENDORFF W.8.Ch.8,0.O.H, 0.C.H, Dip Ost DDR LOURENS DE KOCK 11.8.Ch.B, BSc(Hons),D.O.. ‘DR AJIT DAYA M.8.Ch.B, BSH), 0.0. [DR GORDON GREEFF M.8.Ch.8,0.0.N,DR KJ GOLDBERG Suite 1611 CBMH CAPE TOWN To Dr. Gordon Greef Andreo Evangelo 13633 9/5/22 Dear Gordon many thanks for the referral. Andreo is 64 yrs old and presents with right iliac fossa pain and change in bowel habit over the past year. Of interest is that he had a cholecystectomy a year ago. O/E He has got a mass palpable in the right iliac fossa. $/I CT- scan : lesion in the ascending colon with intraperitoneal mets , plus a large met in the liver. ‘As discussed with you he will need a multi disciplinary appoach with surgery and chemotherapy . I think he would do better in his home country. Kind regards we? Dr. KJ GoldbergDrs. Rosendorff, De Kock, Daya & Greeff (Inc) 101 THE ANNEXE, Tel: 021-424-2003 Christiaan Bariard Memorial Hospital, Fax: 021-424-2023 ‘Suite 1201 Foreshore info@airseamed.co.za Capetown, 8001. 07.05.2022 Andreo Evangelio Ex Miv Cygnus. The above seen on the 6" May complaining of increasing suprapubic discomfort and painful micturition. Urinalysis did not support a UTI. ACT scan on the 7" showed a suspicious lesion in large bowel with incomplete small bowel obstruction. He requires urgent hospitalization He presently unfit for sea duty or repatriation by air. ay Dr. GJ Greeff. osendortt De Sea 4 erent (En oeh sure 201 Ta AAMT Ea. Hosea, ors iNiS ba JEL vat 24 424-2003DIOLOGISTS umber: 98 (hy MORTON & PARTNERS 8 Deters 398 DrGOlies OrGEBHactng OriMauertesN Or 6.x DrWkujs DrAleiy GrBSAokor Gro Meine OFF Puenever DrTNar Ork Psran Dr DrPSchoKs OF OW Seetyn Ore USSR Asocanes: DrD cramer OrRogesar OrFJonters OriMenng BriiNlrthy Ora Rhozes Ort 8 rss Sonate OF PATIENT: EVANGELIO, ANDREO (QP-1213343) (64 y) PATIENT ID: @P-4213343 ADDRESS: M/V CYGNUS, UNKNOWN, ‘TELEPHONE: STUDY DATE: 97-May-2022 10:39 VISIT NUMBER: CBMH4416927 REFERRING DR: DR ROSENDORFF, GRAHAM CT ABDOMEN PRE & POST CONTRAST CLINICAL, Patient with lower abdominal pain. Painful micturition, 64-year-old male. TECHNICAL FACTORS Routine pre, arterial and portal venous phase imaging of the abdomen and pelvis performed. FINDINGS ‘There is an apple core lesion situated within the ascending colon/cecal pole junction. This measures 7 cm in craniocaudal length by 4.7 x 5 om in transverse diameter. This causes a high grade small bowel obstruction with dilatation and air-fluid levels seen throughout the small bowel loops. Slight irregularity noted to the junction of the sigmoid and rectum. This most likely represents collapsed loops of bowel but direct visualisation is recommended to exclude a tandem lesion There are several peritoneal metastases noted. ‘The largest peritoneal metastasis is situated within the right upper quadrant, at the level of the right liver lobe, measuring 10 the metres in short axis. Further adjacent smaller peritoneal metastases noted. Isolated peritoneal metastasis situated within the right hemipelvis at the level of the rectosigmoid junction (measuring 11 mm in short axis) ‘There is a 3.8 cm hypodense lesion seen along the subcapsular aspect of segment 5 of the liver, consistent with liver metastasis. ‘The remainder of the liver is homogenous in appearance. Features of previous cholecystectomy noted. No biliary tree abnormalities The pancreas and spleen are normal. The bladder are normal No signs of hydroureter / hydronephrosis. ‘The lung bases are clear. No aggressive appearing bony lesions seen on available imagingCOMMENT Apple core lesion seen occupying the junction between the cecal pole and ascending colon, This causes high grade bowel obstruction with dilatation and air-fluid levels seen throughout the small bowel loops. Collapsed loop of bowel seen along the rectosigmoid junction but slight irregularity at this level raises the possibility of a tandem lesion within the colon, ‘These findings would favour colonic cancer until proven otherwise. Colonoscopy recommended Peritoneal metastases seen within the right upper quadrant mesentery as well as within the right hemipelvis. Isolated liver metastasis situated within segment 5 of the liver ‘The visualised lung fields are clear. No aggressive appearing bony lesions seen. The patient may benefit from a CT scan of the chest to assess for a mid to upper lobe pulmonary metastases Icp10 R93.2, ROB.3, RO3.5 DR VISAGIE, RUAN Report verified by: DR VISAGIE, RUAN - 07-May-2022 11:29