PERSONAL SOCIAL HISTORY

Mr. M.H. is the youngest in their family. He has 2 brothers and 1 sister. At the age of 14, the patient started to become
a smoker and drinker. He used to drink liquor with his friends during his free time. He consumed 1-2 packs of cigarette and 1-2
bottle of gin four times a week. In terms on his exercise he plays basketball with his friends. When he reached the age of 16, he
started earning money by driving their own tricycle after attending on his classes to support his vices. At the age of 17, he
graduated from high school and did not pursue his study in college. He already consumed 2-3 packs of cigarette and 1-2 bottles
of gin six times a week. He had an intimate and committed relationship with his girlfriend at the age of 20. He has a lot of friends
and some of them influenced him to smoke (fortune cigarettes) and drink liquor (gin).

PAST HISTORY
He had a complete vaccination of BCG, OPV, DPT, Hepa-B, and Measles. He had no known allergy to food. Cough
and colds is one of his childhood illnesses and because they cannot afford to buy medication the illness became worst. In 1985, at
the age of 1, he was brought to Bataan Provincial Hospital with chief complaint of prolonged cough and colds and diagnosed to
have bronchopneumonia and was given some medication like bronchodam and clariget. Their environment has poor living
condition and during those times their source of water came from water pump. In 1987, at the age of 3, he was brought again to
Bataan Provincial Hospital with complaints of severe abdominal pain and frequent passage of watery stool. He was diagnosed to
have Amoebiasis and was given medication of metronidazole. Last 2005, he experience 3 days of high grade fever that lead to
convulsion and was rushed at St. Michael Hospital and he was confine for one week, and later diagnosed to have seizure and was
given medication like dilantin.

FAMILY HISTORY
Mr. M.H. mother side has a history of diabetes mellitus. Both sides of his parents have no history of cancer, mental
disorder, hypertension, tuberculosis and liver cirrhosis.

PRESENT HISTORY
Three days prior to admission, the patient had complaints of epigastric pain, fever, and body weakness. He was
admitted in Bataan General Hospital on November 1, 2009 at 11:50 pm under the care of Dr. Almario Malixi with initial
diagnosis of jaundice with icteric sclera. He was given an IVF of PNSS 1 liter and oxygen inhalation of 2-3 lpm via nasal
cannula. Before we handle the patient he is undergone laboratory test of Hematology on November 5, 2009, he has a decreased
Hemoglobin and Hematocrit, while on his Blood Chemistry he has decreased level of sodium and potassium. On November 6,
2009, after the readings of his result in hematology Dr. Malixi requests to have 4 units of PRBC with blood type A. When we
handle the patient on November 9, 2009 he was conscious and coherent, pale and weak in appearance, warm to touch. He has
difficulty of breathing with use of accessory muscle, sparse body hair and pruritus. His lips are dry and cracked, he has a bleeding
gums and with bruises on upper extremities. He has bloated stomach with abdominal girth of 34 cm. and bipedal edema of 2+.
An indwelling Foley catheter was inserted due to inability to void. Upon the interview the patient claim that he has a hemorrhoid
that’s why he had difficulty in defecating. His initial vital signs was temperature (38.5°C), respiratory rate (32 bpm), pulse rate
(73 bpm), and blood pressure (110/70 mmHg) and on November 10, 2009 Dr. Malixi ordered him to have abdominal ultrasound
but he cannot afford to undergo the abdominal ultrasound. On November 11, 2009 the patient manifested disorientation, delirium
and hallucination.
Because of unavailability of the blood and financial problem the patient was not able to undergo blood transfusion.
Only on November 16, 2009, at 3:35 pm, he was given 1 unit of PRBC type A.