December 30, 2023

Embassy of Japan in the Philippines

2627 Roxas Boulevard, Pasay City, 1300

Metro Manila, Philippines

Dear Sir/Madam:

I am writing this letter to explain why I am unable to present an Income Tax Return (ITR) for my
visa application.

I have made it a lifestyle to travel. Just for this year 2023, I have been to countries such as Egypt,
Israel, Jordan, Singapore and Hongkong. This year, I hope to go back to Japan, if given another
tourist visa.

Thank you for reviewing my application.

Problem84 Process Location Quality

Gastroesophageal
Reflux Disease
(GERD)11,14
Prolonged exposure of esophagus to
gastric acid due to impaired esophageal motility or excess relaxations of
the lower esophageal sphincter; Helicobacter pylori may be present
Chest or epigastric Heartburn, regurgitation
Peptic Ulcer and
Dyspepsia3,5
Mucosal ulcer in stomach or duodenum >5 mm, covered with fibrin, extending through the
muscularis mucosa; H. pylori infection present in
90% of peptic ulcers
Epigastric, may radiate straight to the
back
Variable: epigastric gnawing
or burning (dyspepsia);
may also be boring, aching,
or hungerlike
No symptoms in up to
20%
Gastric Cancer Adenocarcinoma in 90%–95%, either
intestinal (older adults) or diffuse
(younger adults, worse prognosis)
Increasingly in “cardia” and GE junction; also in distal stomach
Variable
Acute Appendicitis17,18 Acute inflammation of the appendix
with distention or obstruction
Poorly localized periumbilical pain,
usually migrates to the right lower
quadrant
Mild but increasing, possibly cramping
Steady and more severe
Acute Cholecystitis10 Inflammation of the gallbladder, from
obstruction of the cystic duct by gallstone in 90%
Right upper quadrant or epigastrium;
may radiate to right shoulder or interscapular area
Steady, aching
Biliary Colic Sudden obstruction of the cystic duct
or common bile duct by a gallstone
Epigastric or right upper quadrant;
may radiate to the right scapula and
shoulder
Steady, aching; not colicky
Usually last longer than
3 hrs
Acute Pancreatitis7,9 Intrapancreatic trypsinogen activation
to trypsin and other enzymes, resulting in autodigestion and inflammation
of the pancreas
Epigastric, may radiate straight to the
back or other areas of the abdomen;
20% with severe sequelae of organ
failure
Usually steady
Chronic Pancreatitis Irreversible destruction of the pancreatic
parenchyma from recurrent inflammation of either large ducts or small ducts
Epigastric, radiating to the back Severe, persistent, deep
Pancreatic Cancer85,86 Predominantly adenocarcinoma
(95%); 5% 5-yr survival
If cancer in body or tail, epigastric, in
either upper quadrant, often radiates to
the back
Steady, deep
Acute Diverticulitis87 Acute inflammation of colonic diverticula, outpouchings 5–10 mm in
diameter, usually in sigmoid or descending colon
Left lower quadrant May be cramping at first,
then steady
Acute Bowel
Obstruction
Obstruction of the bowel lumen, most
commonly caused by (1) adhesions or
hernias (small bowel), or (2) cancer or
diverticulitis (colon)
Small bowel: periumbilical or upper
abdominal
Colon: lower abdominal or generalized
Cramping
Cramping
Mesenteric
Ischemia88,89
Occlusion of blood flow to small
bowel, from arterial or venous thrombosis (especially superior mesenteric
artery), cardiac embolus, or hypoperfusion; can be colonic
May be periumbilical at first, then
diffuse; may be postprandial,
classically inducing “food fear”
Cramping at first, then
steady; pain disproportionate to examination findingsC H A P T E R 11 | The Abdomen 489
Timing Aggravating Factors Relieving Factors
Associated Symptoms
and Setting
After meals, especially spicy
foods
Lying down, bending over;
physical activity; diseases such
as scleroderma, gastroparesis;
drugs like nicotine that relax the
lower esophageal sphincter
Antacids, proton pump inhibitors; avoiding alcohol, smoking,
fatty meals, chocolate, selected
drugs such as theophylline, calcium channel blockers
Wheezing, chronic cough, shortness of breath, hoarseness, choking
sensation, dysphagia, regurgitation,
halitosis, sore throat; increases risk
of Barrett esophagus and esophageal cancer
Intermittent; duodenal ulcer is
more likely than gastric ulcer
or dyspepsia to cause pain that
(1) wakes the patient at night,
and (2) occurs intermittently
over a few wks, disappears for
months, then recurs
Variable Food and antacids may bring relief (less likely in gastric ulcers)
Nausea, vomiting, belching, bloating;
heartburn (more common in duodenal
ulcer); weight loss (more common in
gastric ulcer); dyspepsia is more common in the young (20–29 yrs), gastric
ulcer in those over 50 yrs, and duodenal
ulcer in those 30–60 yrs
Pain is persistent, slowly progressive; duration of pain is typically shorter than in peptic ulcer
Often food; H. pylori infection Not relieved by food or antacids Anorexia, nausea, early satiety,
weight
loss, and sometimes bleeding; most
common in ages 50–70 yrs
Lasts roughly 4–6 hrs, depending on intervention
Movement or cough If it subsides temporarily,
suspect perforation of the
appendix.
Anorexia, nausea, possibly vomiting,
which typically follow the onset of
pain; low fever
Gradual onset; course longer
than in biliary colic
Jarring, deep breathing Anorexia, nausea, vomiting, fever;
no jaundice
Rapid onset over a few min, lasts
one to several hrs and subsides
gradually; often recurrent
Fatty meals but also fasting;
often precedes cholecystitis,
cholangitis, pancreatitis
Anorexia, nausea, vomiting, restlessness
Acute onset, persistent pain Lying supine; dyspnea if pleural
effusions from capillary leak syndrome; selected medications,
high triglycerides may exacerbate
Leaning forward with trunk
flexed
Nausea, vomiting, abdominal distention, fever; often recurrent; 80%
with history of alcohol abuse or
gallstones
Chronic or recurrent course Alcohol, heavy or fatty meals Possibly leaning forward with
trunk flexed; often intractable
Pancreatic enzyme insufficiency,
diarrhea with fatty stools (steatorrhea) and diabetes mellitus
Persistent pain; relentlessly
progressive illness
Smoking, chronic pancreatitis Possibly leaning forward with
trunk flexed; often intractable
Painless jaundice, anorexia, weight
loss; glucose intolerance, depression
Often gradual onset Analgesia, bowel rest, antibiotics Fever, constipation. Also nausea,
vomiting, abdominal mass with
rebound tenderness
Paroxysmal; may decrease as
bowel mobility is impaired
Paroxysmal, though typically
milder
Ingestion of food or liquids Vomiting of bile and mucus (high
obstruction) or fecal material (low
obstruction); obstipation develops
(early); vomiting late if at all; prior
symptoms of underlying cause
Usually abrupt in onset, then
persistent
Underlying cardiac disease Vomiting, bloody stool, soft distended abdomen with peritoneal
signs, shock; age >50 yrs490 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I
STORYTAKING
Table 11-2 Dysphagia
Process and
Problem Timing
Factors That
Aggravate
Factors That
Relieve
Associated
Symptoms and
Conditions
Oropharyngeal
Dysphagia
Acute or gradual onset
and a variable course,
depending on the
underlying disorder
Attempts to start the
swallowing process
Aspiration into the
lungs or regurgitation
into the nose with
attempts to swallow;
from motor disorders
affecting the
pharyngeal muscles
such as stroke, bulbar
palsy, or other
neuromuscular
conditions
Esophageal Dysphagia
Mechanical Narrowing
Mucosal rings and webs Intermittent Solid foods Regurgitation of the
bolus of food
Usually none
Esophageal stricture Intermittent; may
become slowly
progressive
Solid foods Regurgitation of the
bolus of food
A long history of
heartburn and
regurgitation
Esophageal cancer May be intermittent at
first; progressive over
months
Solid foods, with
progression to liquids
Regurgitation of the
bolus of food
Pain in the chest and
back and weight loss,
especially late in the
course of illness
Motor Disorders
Diffuse esophageal
spasm
Intermittent Solids or liquids Maneuvers described
below; sometimes
nitroglycerin
Chest pain that mimics
angina pectoris or
myocardial infarction
and lasts min to hrs;
possibly heartburn
Scleroderma
Achalasia
Intermittent; may
progress slowly
Intermittent; may
progress
Solids or liquids
Solids or liquids
Repeated swallowing;
movements such as
straightening the back,
raising the arms, or a
Valsalva maneuver
(straining down
against a closed
glottis)
Heartburn; other
manifestations of
scleroderma
Regurgitation, often at
night when lying
down, with nocturnal
cough; possibly chest
pain precipitated by
eatingC H A P T E R 11 | The Abdomen 491
Table 11-3 Diarrhea
Problem Process
Characteristics
of Stool Timing
Associated
Symptoms
Setting,
Persons at
Risk
Acute Diarrhea90 (Ä14 days)
Secretory
Infection (Noninflammatory)
Infection by viruses, preformed
bacterial toxins
(such as Staphylococcus aureus, Bacillus cereus, Clostridium perfringens,
toxigenic Escherichia coli, Vibrio
cholerae), cryptosporidium, Giardia
lamblia, rotavirus
Watery, without blood,
pus, or mucus
Duration of a few
days, possibly longer; lactase deficiency may lead to
a longer course
Nausea, vomiting,
periumbilical
cramping pain;
temperature normal or slightly
elevated
Often travel, a
common food
source, or an
epidemic
Inflammatory
Infection
Colonization or invasion of intestinal
mucosa (nontyphoid Salmonella,
Shigella, Yersinia,
Campylobacter, enteropathic E. coli,
Entamoeba histolytica, C. difficile)
Loose to watery, often
with blood, pus, or
mucus
An acute illness of
varying duration
Lower abdominal
cramping pain and
often rectal urgency, tenesmus;
fever
Travel, contaminated food or
water; frequent
anal intercourse
Drug-Induced
Diarrhea
Action of many
drugs, such as
magnesium-containing antacids,
antibiotics, antineoplastic agents,
and laxatives
Loose to watery Acute, recurrent,
or chronic
Possibly nausea;
usually little if any
pain
Prescribed or
over-the-counter
medications
Chronic Diarrhea (ê30 days)
Diarrheal Syndrome
Irritable bowel
syndrome20
Altered motility or
secretion from luminal and mucosal
irritants that
change mucosal
permeability, immune activation,
and colonic transit,
including maldigested carbohydrates, fats, excess
bile acids, gluten
intolerance, enteroendocrine signaling, and changes in
microbiomes
Loose; ∼50% with
mucus; small to moderate volume. Small,
hard stools with constipation. May be
mixed pattern.
Worse in the
morning; rarely at
night.
Crampy lower abdominal pain, abdominal distention, flatulence,
nausea; urgency,
pain relieved with
defecation
Young and
middle-aged
adults, especially women