INFORMANT: Patient and wife

RELIABILITY: 98%

This is a case of RA, 59 year old male, a sari-sari store owner from Lucena City

History of Present Illness:

The history of present illness started about 2 months prior to admission when patient
experienced pain on his left lateral buttocks (gluteal) area radiating to the posterolateral surface
of his left leg causing discomfort with of PS 6/10. Patient self medicate with Celecoxib 400mg
cap OD with some relief.
3 weeks prior to admission, pain became more severe PS 8/10 and started to have
difficulty in ambulation. Online consult done to a private MD, given Tramadol 50 TID, Etoricoxib
120 mg OD and Pregabalin 75 OD with temporary relief.
1 day prior to admission, patient became unambulatory because of severe pain, thus
the admission.

Past Medical History:

Patient underwent Craniotomy for evacuation of subdural hematoma secondary to

traumatic head injury last 2014 at JRMMC. He is known hypertensive with Losartan 50 as his
maintenance meds.

Family History:

Has family history of hypertension and diabetes on both paternal and maternal sides.
His eldest brother has diabetes, his eldest sister has hypertension, diabetes and died of breast
cancer. His 3 other sisters are all hypertensive and his youngest brother has history of Psoriasis.

Personal and Social History