Informant: Himself Consultant: Dr. Marlene Checa Reliability: Good Date Submitted: April 14, 2014 Historian: Anthony Gerodias Date Taken: April 11, 2014
IN SERVICE NOTES CLINICAL HISTORY I. General Data A.D, 26 year old, male, Filipino, Roman Catholic, Single, self-employed, currently residing in Batas Sector III, General Emilio Aguinaldo, Cavite, admitted under the care of the Department of Family and Community Medicine on April 11, 2014. II. Chief Complaint Masakit na likod III. History of Present Illness 4 weeks prior to admission, the patient experienced a middle back pain after lifting stacks of wood. The pain was characterized as dull in character, was 7/10 in the pain scale, and was more lateralized to the left side of his body. No other signs and symptoms such as upper/lower extremity weakness, loss of sensation, or fever were noted. He opted bed rest however it provided no relief. 3 weeks prior to admission, the dull back ache still persisted so the patient sought a hilot. The hilot visited the patient for 2 consecutive days, stretching and massaging the affected area but it still provided no relief. The pain is aggravated by heat and exertion. It occurred almost every day of the week and each episode lasted the whole day. He also reported the pain to migrate to other regions of the patients back which provided him distress. He took no medications and no consult was done. The pain persisted, but is again lateralized in the left middle back, until the patient sought consult during the regular rounds of the residents in the community on April 11, 2014. IV. Past Medical History The patient was hospitalized in Batangas on 2012 when he was diagnosed with Dengue. There he stayed for 4 days and was given Paracetamol and Dextrose solution. During the same year, he was also involved in a motorcycle accident where he obtained minor injuries all over his body. He opted not to stay in a hospital but was prescribed with Mefenamic Acid and unrecalled antibiotics. 2 weeks prior to admission, the patient got bitten by a stray dog. He has reportedly completed his anti-rabies vaccinations. confirm The patient has no history of cancer, diabetes mellitus, hypertension, heart, liver, lung, or kidney diseases. No known allergies to drugs and food were noted.
V. Family History There was no note of cancer, diabetes mellitus, hypertension, heart, liver, lung, or kidney diseases in the family.
VI. Personal and Social History The patient is a smoker with a computed pack years of 10. He started smoking at 16 years old, smoking up to 1 pack a day. The patient is also an alcoholic beverage drinker of unspecified amount. The patient lives alone and resides in a bungalow type
home made of wood. Electricity is provided by Meralco and tap water is provided by LOWA. He has a water sealed toilet and disposes of his trash by burning them.
VII. Review of Systems General: (+) loss of appetite (-) weakness (-) easy fatigability (+) weight loss Integument: (-) pallor (-) clubbing of nails (-) hypo/hyperpigmentation Head: (-) headache (-) dizziness Eyes: (-) blurring of vision, (-) discharge Ears: (-) loss of hearing (-) otalgia Nose: (-) epistaxis (-) obstruction Throat: (-) dysphagia (-) sore throat Respiratory: (-) cough (-) colds (-) chest pain (-) dyspnea Cardio: (-) palpitations (-) angina GIT: (-) diarrhea (-) constipation (-) abdominal pain (-) hematochezia/melena (-) vomiting GUT: (-) frequency (-) dysuria Hematologic: (-) easy bruisability (-) pallor Musculoskeletal: (-) pain Nervous: (-) seizure (-) syncope
PHYSICAL EXAMINATION I. General Survey The patient was well developed, well nourished, awake, conscious, coherent, and oriented to time, place, and person. He appears his chronological age of 26 years old. II. Vital Signs HR: 88bpm RR: 16cpm Temperature: 36.4C BP: 100/60mmHg III. Skin A. General Characteristic Color: (-) pallor (-) jaundice (-) erythema (-) hyperpigmentation Temperature: Warm to touch Turgor: Prompt return after finger pressure Degree of moisture: No dryness, no excess moisture Hardness/Sclerosis or Laxity: (-) sclerosis, (-) laxity B. Skin Lesions 3x3cm scar on the patients right shoulder 3x3cm scar on the patients left knee C. Skin appendages Hair: black, (-) hair loss, (-) hypertrichosis (-) nodules, (-) brittle hair Nails: nail plate: transparent, (-) nail dystrophy, nail bed: (-) nail bed lesions; nail folds: (-) lesions proximal and lateral nail folds D. Mucosal Changes: (-) oral/nasal lesions IV. Head & Neck Hair: Hair has normal texture and are equally distributed Scalp: (-) lumps (-) scales (-) flakes
Skull: (+) normocephalic (+) symmetry (-) lumps (-) tenderness Facial symmetry: (+) symmetry (-) deformities Midline Trachea (-) Webbed Neck (-) Tender cervical lymph nodes (-) Carotid bruits (-) Thyroid enlargement V. Eyes (-) Symmetry (-) Ptosis Pink Palpebral Conjunctiva Icteric Sclera Pupils reactive to light Visual Acuity: not done Fundoscopy: not done VI. Nose (+) Symmetrical external nose (+) Equal size and shape of the external nares (+) Midline Nasal Septum (-) Discharges, masses, lesions (+) pink turbinates Patent nostrils VII. Ears (+) Mobile pinna (-) masses (-) Discharges (+) Patent canal and auditory cavities (-) microtia Tympanic membrane visualization: not done VIII. Mouth (-) Lesions (-) Masses (+) Tongue in midline (+) Smooth and pink mucosa IX. Chest And Lungs A. Inspection AP: transverse diameter= 1:2 (-) masses or lesions (-) deformities or defects on chest wall (-) alar flaring B. Palpation (-) cervical lymphadenopathies (-) masses or lesions on chest C. Percussion not done D. Auscultation (-) crackles (-) wheezes Normal breath sounds
X. Cardiovascular System A. Inspection (-) precordial bulging
B. Palpation (+) all pulses, full and equal C. Percussion- not done D. Auscultation Heart rate= 88 bpm Regular rhythm (-) murmurs XI. Examination Of The Abdomen A. Inspection Flat, symmetrical (-) Scars or lesions (-) Discolorations (-) Visible veins (-) Visible masses (-) Visible peristalsis (-) Visible pulsations B. Auscultation Not performed C. Palpation (-) Masses (-) Tenderness LIVER SPAN D. Percussion- not performed XII. Musculoskeletal Examination The patient is able to ambulate and dress himself without assistance or difficulty A. Inspection (-) Masses (-) Deformities B. Palpation Full and equal peripheral pulses (-) Crepitus (+) Stiffness lateral to the thoracic spinal column (L)
ADAM's test C. Range of Motion No limitation on range of motion XII. Neurologic Examination a. Mental Status The patient appeared conscious, coherent, and well groomed. Her speech was continuous with a soft voice. b. Cranial Nerves CN I: adequate smell sensation CN II and III: + direct and consensual pupillary light reflex CN III, IV, VI: EOM functioning, (-) ptosis CN V: Motor: adequate function of masseter and temporalis muscle CN VII: symmetrical facial contours c. Motor System
5/5 5/5 5/5 5/5 5/5 5/5
CASE DISCUSSION CAGE QUESTIONNAIRE!!! Primary Impression: Upper/Middle Back Strain This is a case of A.D., 26 years old, male who was admitted under the care of the Department of Family and Community Medicine on April 2014 due to upper/middle back pain. A muscle strain occurs when there is overstretching or overuse of a muscle to the point of tearing. The occurrence of upper/middle back strain is lower compared to lower back strain as the thoracic vertebra is usually for protection of vital organs and not for weight bearing. However, in the case of A.D., it can be a combination of factors such as he did not have proper posturing while carrying the heavy load of wood, overuse, or carrying a load which his body cannot take. The migrating nature of the pain lessens the probability that there is bone involvement. Overall, a dull pain with muscle stiffness to the left of the spinal column suggests that only muscle is involved. However, there are signs and symptoms that should be watched out for in these situations. These are; signs of nerve involvement such as weakness or changes in sensation in the extremities, loss of bowel/bladder control. These, when present, may indicate that there is spinal cord compression and will need more attention. Management: A thorough physical exam by a trained practitioner can usually be enough to accurately diagnose the patients condition. However, imaging tests can be requested in order to confirm or rule out diagnoses. An X-ray would be a cheap procedure which could provide clues if the cause of the patients pain is a broken bone. However, an MRI would provide a clearer picture and could confirm if there is a herniated disc. RICE - rest, icing, compression, and elevation is the first line treatment for a muscular strain. However, pain relievers can be taken if it still persists. The patient was prescribed with mefenamic acid, a non-steroidal anti-inflammatory drug, which he can take in order to alleviate the symptoms. Overall, rest and avoidance of strenuous activities would be enough for the patients condition. And if the pain still persists, then further work-ups such as the imaging studies described above would be required.
FAMILY REPORT I. Family Lifeline The patient belongs to a single household with a matrilocal residence. II. Family Profile Family Member Age Sex Civil Status Educational Attainment Occupation Average Financial Contribution Alberto Dimaano 52 M Married High School Graduate Welder - Leoncia Dimaano 51 F Married High School Graduate Sari-sari Store Owner - Amy D. Bautista 35 F Married High School Graduate Courier - Lenny Dimaano 31 F Single College Graduate Working Abroad - Alexander Dimaano (Index Patient) 26 M Single College Graduate Pig Breeder Cannot be estimated Aileen D. Valentino 24 F Married High School Graduate Housewife - III.
III. Family Genogram
IV. Environmental Profile The patient lives in a single storey house made of wood. There is adequate ventilation and lighting inside the house. His house is easily accessible and near the main road. Electricity is supplied by Meralco and water is supplied by LOWA. The patient uses tap water as drinking water. The toilet is of the water- sealed type and garbage is disposed of by burning. V. Economic Profile The patient claims to have only started his pig breeding business recently and is living off savings and support from his family. He cannot give an estimate of his yearly income as of yet.
VI. Family Mapping
Expenses Food Utilities Business Others
VII. Assessment of Family Function APGAR Part I
Palagi (2) Paminsan- minsan (1) Halos Hindi (0) A Akoy nasisiyahan dahil nakakaasa ako ng tulong sa aking pamilya sa oras ng mga problema
P Akoy nasisiyahan sa paraang pakikipagtalakayan sa akin and aking pamilya tungkol sa aking suliranin
G Akoy nasisiyahan at ang aking pamilya ay tinatanggap at sinusuportahan ang aking mga nais na gawin patungo sa mga bagong landas ng aking ikauunlad
A Akoy nasisiyahan sa paraang ipinadadama ng aking pamilya ang kanilang pagmamahal at nauunawaan ang aking damdamin tulad ng galit, lungkot, at pag-ibig
R Akoy nasisiyahan na ang aking pamilya at ako ay nagkakaroon ng panahon para sa isat-isa
The patient scored 6 in the APGAR, which indicates that the patient has a moderately dysfunctional family.
APGAR Part 2 Name Age Gender Relationship Quality Alberto Dimaano 52 M Father Good/Functional Leoncia Dimaano 51 F Mother Good/Functional Amy Bautista 35 F Sister Good/Functional Lenny Dimaano 31 F Sister Very Good/Functional Alexander 26 M - -
Dimaano Aileen Valentino 24 F Sister Good/Functional
The patient currently lives alone away from his parents and siblings. He claims to have a good relationship with all of the members of his family but he is closest to her older sister, Lenny. SCREEM Social No Pathology The patient can turn to his family and friends in times of illness even if they do not live with each other anymore. Cultural No Pathology The family does not belong to an indigenous group, however from time to time he consults with hilots and arbularyos. He does not believe that otherworldly creatures are the cause of his illness Religion No Pathology The patient is a practicing Roman Catholic and states that he believes in God but does not think God give him the illness he is currently having. Economic Slight Pathology The patient currently has no steady means of income. However he can still ask financial aid from his family if he needs it. Educational No Pathology The patient is a college graduate and can differentiate what treatment is good for him and what is not beneficial. Medical No Pathology The patient understands his condition and is open to medical advice.
VIII. Family/Individual Reaction to Illness The patient is distressed by the pain which has already lasted for a month. He is open to suggestion and appears to be willing to follow the treatment regimen that is given to him. IX. Assessment of Impact of Illness There is limitation in the patients ability to work due to his illness. However, he is still independent and can still fend for himself. X. Recommendations for the Family The patient should opt to rest his body more as he appears to exert himself now and again which aggravates his condition. He should avoid strenuous activities for the time being and if it cannot be avoided, it should be limited or he could ask
some of his friends for now. If the back pain persists, he can take the medicine (Mefenamic Acid) prescribed to him in order to provide symptomatic relief.