ALLAH VALLEY MEDICAL SPECIALISTS' CENTER, INC.

Purok Villegas, Gensan Drive, Koronadal City

Telefax # (083)228-5037 / Tel.# (083)228-3550
Email Address: avmsci@yahoo.com

SOCIAL CASE STUDY

April 15, 2024

I. IDENTIFYING DATA
NAME : WALGENBACH, JAMES LE ROY
AGE : 82 years old
SEX : Male
CIVIL STATUS : Expired
RELIGION : Baptist
BIRTH DATE : march 19, 1942
PLACE OF BIRTH : Wisconsin USA
EDUCATIONAL ATTAINMENT : College Level
OCCUPATION : Senior Citizen
ADDRESS : Prk. Rizal Puti Norala
II. FAMILY COMPOSITION

NAME RELATIONSHIP AGE OCCUPATION EDUC.ATTAINMENT

TO PATIENT
Ruth Cachuela Girlfriend 52 Sari-sari Store owner College Level
Aleiah Yzabel Reeves Daughter 7 Grade 1

III. PROBLEM PRESENTED

Patient’s girlfriend, came to the office seeking financial help in order to defray the patient’s
hospitalization, medication and doctors fee here at Allah Valley Medical Specialists Center Inc., Hospital
as he is given an admitting diagnosis of Acute Respiratory Failure Type I and Type IV, Community
Acquired Pneumonia, High-Risk, septic Shock, Presumptive Pulmonary Tuberculosis, Diabetes Mellitus
Type II, Multiple Electrolyte Imbalance ( Hypocalcemia, Hypomagnesaemia, Hypoalbuminiea, Acute
Kidney Injury Secondary to;1) Renal Hyperfusion, 2) Sepsis. ( px.expired)

IV. FAMILY BACKGROUND/ SOCIO-ECONOMIC STATUS

Patient is an American National and only came in the Philippines to visit her girlfriend. He was in
relationship for 1 month with Ms. Ruth Cachuela, a single mother and has a small sari-sari store in front
of her house. Patient’s whereabouts is unknown according to the girlfriend since they just got to each
other for a very short period of time. His girlfriend was able to reach and communicate with his siblings
in Unite States of America however; they disclosed that they won’t extend any financial amount for the
hospitalization and burial expenses of the patient. As stated by the girlfriend they vocally abandoned the
patient and whatever happens they won’t care anymore. All the needs of the patient is voluntarily given
 by the girlfriend’s relative s and friends. She sustained of their needs through her daily income in the
small sari-sari store.

V. HISTORY OF ILLNESS

Patient has cough for two weeks, they seek medical intervention and by then it was determine
that patient has low oxygen level, hypotension and diabetic. This made him immediately referred at the
complete hospital facility yet due to his critical condition he was then confined at the intensive care unit
for 1 day and 1 night, later he became unresponsive hence declared expired by the attending physician
due to his Acute Respiratory Failure Type I and Type IV, Community Acquired Pneumonia, High-Risk,
septic Shock, Presumptive Pulmonary Tuberculosis, Diabetes Mellitus Type II, Multiple Electrolyte
Imbalance ( Hypocalcaemia, Hypomagnesaemia, Hypoalbuminiea, acute Kidney Injury Secondary to;1)
Renal Hyperfusion, 2) Sepsis.

VI. ASSESSMENT & RECOMMENDATION

As per assessment of the undersigned, patient family is already financially exhausted and could
no longer afford to settle his hospitalization, medication, and doctor’s fee that incurred the total
amount of Php 137,914.47, in excess to his partial payment amounting to Php 65,000.00. Patient is not
a Filipino which made him not qualified to avail Philhealth.

Hence, referral is made to avail financial assistance.

Prepared by

MA. IMEE A. BERBER, RSW

Medical Social Worker
Lic# 0027395
AVMCSCI-CS2024I- 04024