Health History

Brief description of the patient

Name: Suarez, Constantine

Age: 74
Gender: Male
Religion: Catholic
Marital status: Married
admitted under the service of Dr. Tan.
Brief description of the patient

Born in the Municipality of Cauayan, Negros Occidental.He was a truck driver of

sugar canes since he was 20 years old. He had retired from that job when he was
65 years old. At the present, he happily tends to his chickens and backyard fruits
and vegetables.
Social History

He denies smoking and illicit drug use. He would occassionally drink coconut wine
(tuba) with his friends during birthdays and special occasions. He had persistent
cough with whitish sputum for a period of 3 weeks, therefore, seeking consultation.
He was diagnosed with tuberculosis for 2 months now. He gets his free supply of
TB medications from the barangay health center under the government's TB
DOTS program.
History of Present Illness/Presenting problem

1 day prior to admission, patient was at the

bathroom taking a bath when he had
slipped off the floor. His son immediately
came to his rescue and he was brought to
the municipal health center with the chief
complaint of deformity of the right leg. An
xray was done and he was referred to this
institution for further treatment.
Laboratory Results
CBC: Normal Values:
HCT 0.38 0.40 - 0.54 L/L
RBC 3.94 4.50 - 5.50 10^12/L
HGB 85 130.00 - 180.00 g/L
WBC 15.3 4.50 - 11.00 10^9/L
Lymphocytes 12
25.00 - 35.00 %
Mono 6
0.00 - 15.00 %
Basophil 1
0.00 - 1.00 %
Platelet 141
150.00 - 400.00 10^9/L
Laboratory Results
Blood Chemistry Profile: Normal Values:
Na 136 135.00 - 145.00 mmol/L
K 3.7 3.50 - 5.00 mmol/L
Crea 73 53.04 - 114.92 umol/L
BUN 6.1 2.80 - 6.40 mmol/L
Laboratory Results
Arterial Blood Gas: Normal Values:
Ph 7.42 7.35 - 7.45
PCO2 39 35.00 - 45.00 mmHg
PO2 93 80.00 - 100.00 mmHg
HCO3 25.3 22.00 - 26.00 mmol/L
Beb 0.8 0.00 - 0.00 +/- 2.00 mmol/L
BE ecf 0.8 0.00 - 0.00 +/- 2.00 mmol/L
O2 sat 97 95.00 - 100.00 %
Laboratory Results
Xray Chest AP:
Bilateral PTB with cavitary formations;
Heart is not enlarged; atherosclerotic
aorta, spondylosis deformans noted.
Laboratory Results
CT Scan, Chest plain:
Findings in both lungs sequelae of PTB; Tiny nodules in the left lung are likely
granulomas, but metastasis cannot be ruled out; Small nodular opacities in the
right upper lobe appears to be bronchial secretions; Atherosclerotic aorta and
coronary arteries; Degenerative osseous changes, thoracolumbar spine;
Osteopenia; Porcelain gallbladder with lithiasis.

Prostate Specific Antigen: 3.35

Laboratory Results
Gram Stain Culture and Sensitivity (1) Soft Tissue (2) Bone:
Negative for AFB; Gram stained smears show few pus cells and no
microorganisms noted