EASTERN VISAYAS REGIONAL MEDICAL CENTER Department of Mdicine Tacloban City Date of interview Source Referral Reliability IDENTIFYING

DATA: B.M., 24, male, single, Roman Catholic, a resident of Barangay Calbasag Julita, Leyte admitted for the 4th time. He is a former chef. CHIEF COMPLAINT: dyspnea HISTORY OF PRESENT ILLNESS 3 weeks PTA, the patients experienced easy fatigability and productive cough with whitish sputum amounting to 2-3 tbsp per episodes. 1 week PTA, above symptoms persisted, now accompanied with gradual onset of edema that started on the right arm followed by edema on the neck and face on the next day. 5 days PTA, bipedal edema was then noted with worsening of the above symptoms. He also experienced dyspnea upon rest, which is aggravated by supine position and relieved by using 5 pillows. : August 23, 2012 : patient and sister : none : 100%

PAST HISTORY There are no recalled childhood illnesses. Immunizations are complete. MEDICAL: October 10, 2010 1st admission at Burauen District Hospital with a chief complaint of cephalgia. He stayed for three days. Unrecalled herbal decoction was given. He was partially relieved. Other medical interventions were unrecalled. He had weekly check-up from January to July 2011 in the same hospital.

October 1, 2011 2nd hospitalization at EVRMC with a chief complaint of cough and dyspnea. He was diagnosed with Non-Hodgkins Lymphoma after an excisional biopsy was done. He underwent CT Scan and revealed a mass on his heart (unrecalled location and size). October 16, 2011 3rd hospitalization at Philippine General Hospital, he underwent CT Scan again to reconfirm his cardiac mass. He was advised for chemotherapy and radiation therapy but they were limited with financial constraints. The patient was prescribed with the following medications which he took with good compliance: Levofloxacin (loxeva) 750 mg ) once a day Calcium + Vit. D (Calvit) 1 tab once a day SURGICAL: October 15, 2011 excision of a cyst on the right axillary area at EVRMC PSYCHIATRIC: none FAMILY HISTORY: The patients grandparents both on the maternal and paternal sides were all deceased due to old age. His father, 59 years old, is alive and apparently well. His mother, 52 years old, has an underlying problem as evidenced by jugular vein distention upon coughing. He is the 4th of 8 children. All his brothers and sisters are alive and apparently well. There is no history of hypertension, diabetes, cancer, heart problem, kidney problem. PERSONAL AND SOCIAL HISTORY: Patient B.M. was a former chef of Chowking (Restaurant Imelda Branch). He would usually wake up around 4AM to prepare so he could come by 5AM at his workplace. He, oftentimes, opts to work overtime (until 12-2AM) so he could sustain his financial needs. Aside from their daily physiologic needs (foods and the like), he also partially pays for the tuition fees of some of his siblings. He neither smokes nor drinks alcoholic beverages of any type. He eats 3 meals a day ( 1-2 cups of rice with any viand available). He has no alternative health care practice.

He has sustained harmonious relationship with the entire family and has maintained a well and open communication with them. He also has a girlfriend for 5 years already. No sexual activities were disclosed. Currently, his primary source of stressor is his health condition. He usually finds solace from his family. Sometimes, he would unknowingly cry while verbalizing his anticipated loss. Her mom and younger sister would console her. As a workaholic, he has almost no time for social activities. He has neither leisure activities nor religious affiliations mentioned. But hed, once in a while, attend Sunday mass because, often than not, this is the only time he can