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 oclock 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, patients 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

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.
5 days prior the visit (after 4days of hospital stay) he was then advised
referral to higher center for further evaluation and management, due to financial
constraints, opted to go home against medical advice with take home medication of
multivitamins taken once daily. He was confined to bed with in place catheter. They
sought consultation to manhihilot twice a week, and claimed of temporary relief of
symptoms, with reported range of motion to both extremities but more of the left
leg, now patient reported urge to defecate but still with inplace catether. He can
now move to his sides, and able to sit for a few minutes with assistance. Patient still
claimed of tenderness at the lumbar area with numbness radiating to the lower
extremities.

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, mumps and measles

Surgical history:

There were no history of previous surgical operation/injuries

FAMILY HISTORY

Wife 34 years old, farmer apparently well

1st child male, 15 years old, grade 10, apparently well
2nd child male, 13 years old, grade 7, apparently well
3rd child male, 11 years old, grade 5, with colds (with no medication intake)
4rth child, female, 7 years old, grade 2, apparently well
5th child, female, 4 years old, daycare, apparently well
6th child, male, 1 year old, apparently well

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

PHYSICAL EXAMINATION
Patient was examined on his 10 days after hospitalization, conscious
coherent conversant, lying flat on his bed, not cardiopulmonary distress

General Survey: P.E was done on his 10 th day after the alleged incident. Patient is
male, mesomorph, conscious, coherent, responsive, afebrile, lying on his back with
good eye contact, and with the following vital signs:
Vital Signs:
HR: 80 bpm
RR: 19 cpm
T: 37.4 C
BP: 100/70 mmHg
Skin:
Inspection: Fair complexion, no jaundice, no petechiae, no ecchymoses, no
edema; Pinkish nail beds w/ capillary refill of <1 sec. Nails w/o clubbing or
cyanosis, no hypo/hyperpigmentation
Palpation: Warm dry skin w/ good skin turgor (skin pinch goes back
immediately); with 2.5x2.5cm mass the lumbar at the level of L3-L4, tender,
non-movable
Head:
Inspection: Symmetric. With black, fine, soft, evenly distributed hair. No scalp
lesion or dandruff. No lice no nits.
Palpation: No masses, no tenderness
Eyes:
Inspection: Symmetrical eyebrows with equally distributed hair, no lesions.
Eyelashes are even and not scanty, pinkish palpebral conjunctiva. Anicteric
sclera. No periorbital edema, no ptosis, no dryness, no redness, no exudates.
Ears:
Inspection: Symmetrical, superior border of pinnae aligned with the eyes. No
discharges.
Palpation: No tenderness, no masses.
Nose:
Inspection: Nasal septum at midline. Nose bridge not deviated. Pinkish nasal
mucosa, no discharges, no swelling, no nodules.
Palpation: no sinus tenderness, no swelling

Mouth and Throat:

Inspection: Pinkish lips. No bleeding gums. Buccal mucosa moist & pinkish. Tongue
at midline, no lesion. Uvula at midline. Tonsils not inflamed
Neck:
Inspection: Symmetrical, no lesions. Neck vein not engorged.
Palpation: Supple; trachea at midline, no lumps. Carotid pulse full. No masses
noted
Chest & Lungs:
Inspection: Symmetric with equal bilateral expansion, without retractions, no
deformities, RR at 19 cpm, not labored.
Palpation: No swelling, no tenderness. Symmetric chest expansion.
fremitus equal in all lung fields not decreased.

Tactile

Percussion: Resonant in all lung fields.

Auscultation: Bronchovesicular breath sounds in all lung fields, no crackles,
no wheeze, no rhonchi
Cardiovascular:
Inspection: Carotid pulse full, adynamic precordium.
Palpation: PMI at left 5th ICS MCL. No heaves, no thrills
Auscultation: HR is 80 bpm, regular, synchronous with PR. No murmurs,
bruits, or abnormal heart sounds.
Abdomen:
Inspection: Flat with inverted umbilicus, symmetrical and soft. No scars or
visible pulsation.
Palpation: no tenderness, no masses noted. Liver edge not palpable. Spleen &
kidneys not palpable. Liver span is 5 cm R MCL and 4 cm at MSL
Percussion: Tympanitic in all quadrants
Auscultation: Normoactive bowel sounds (15/min), no bruits in aortic, renal,
iliac and femoral arteries.
Genitourinary: grossly male, with attached catether attached to urobag draining
200cc yellow colored urine; urge to defecate

Back & Spine:

Inspection: no lateral spine deviation, no kyphosis, no lordosis, lump at the
lumbar area
Palpation: with 2.5x2.5 cm mass at the level of L3-L4, tender, nonmovableno;no costovertebral angle tenderness
Musculoskeletal:
Inspection: Symmetrical upper and lower extremities. No muscle atrophy. No
involuntary movements. Incomplete range of motion on both lower
extremities
Palpation: No tenderness, no masses, peripheral pulses are full and
synchronous with HR

Neurologic:
Mental Status: Patient is conscious, awake, alert and oriented to person, place, and
time. His remote and recent memory is intact. Patient understands simple
questions and commands with no difficulty in answering.
Cranial nerves:
I No anosmia
II Visual acuity good, both pupils 2-3mm, equally round, reactive to light and
accommodation.
III, IV, VI full EOM without nystagmus, (+) convergence
V - with well contracted temporalis and masseter muscle upon clenching
teeth.
VII - face is symmetric. Closes both eyes tightly, (-) flattening of nasolabial
fold.
VIII - can hear both usual conversation and whisper. Gross hearing intact
IX, X - uvula at midline, with symmetrical pharyngeal elevation. (+) gag reflex
XI - performs shoulder shrug bilaterally. Turns head against resistance.
XII - Tongue protrudes midline; without deviation. No fasciculation, no tremor,
able to push buccal wall against applied force, without atrophy.
Motor:
No atrophy in all major muscle groups, good tone, strength 5/5 and left
lower extremities. while 3/5 on the lower right extremity

3/5

5/5

Cerebellar function:
Patient can sit without assistance, able to perform finger to nose test; Able to
do rapid alternating movements, can do heel to shin test
Sensory:
Light touch, pinprick, position sense and vibratory sensation intact in extremities

Sensory:
Light touch, pinprick, position sense and vibratory sensation intact on both upper
extree to localize pain on the anterior 2/3 of both lower extremities. Decrease
sensation on posterior 2/3 of both lower extremities.

Deep Tendon Reflexes

Right
Left

Achilles

Patellar

Biceps

Triceps

Brachioradialis

1+
0+

1+
1+

2+
2+

2+

2+
2+

Pathologic Reflexes:
(-) ankle clonus

2+

(-) Babinski reflex

Meningeals
(-) brudzinkis sign
(-) kernigs sign
(-) nucchal rigidity

Autonomic
No bladder and bowel incontinence. No excessive sweating.