Name of Patient: Alexander Dimaano Brgy.

Batas Sector III

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.