A. Past Medical History
The patient was never been admitted before nor diagnose with any serious illness. He does not have history of surgical operations. As part of the military protocol, he annually complies with medical and physical exams. Generally, he is relatively good. Some of the common sickness he experienced throughout the years includes fever, cough and colds, abdominal pain and headache. He usually takes over the counter medications to manage the said common sickness. According to him, he was fully immunized during childhood and received flu vaccine just last year (June, 2013). He does not have known allergies to foods and medications. He tried smoking but did not continue and occasionally he drinks liquor. Few months ago, he took Multivitamins (Centrum) for about three (3) months but stopped because he cannot buy the vitamins due to busy work schedule.
B. History of Present Illness
After his training in Manila, the patient was assigned here in Zamboanga last June 2014. When he arrived here, he was required to take the yearly physical exam as part of the military protocol. His laboratory results including chest x-ray revealed normal results and the physical examination was generally well.
A month prior to admission, Mr. S.B. already started to have cough and manage it by using over-the-counter medications as advised by his friends namely Solmux and Cotrimoxazole. He admitted that he’s noncompliant in taking the said medications. Weeks prior, accompanied by cough, Mr. S.B. started to feel weak that he could not accomplish the activities he usually do like playing basketball. The patient verbalized that he could not complete the basketball game because he’s experiencing difficulty of breathing. Accordingly, his friends noticed that he lose weight but as for him, he failed to recognize it. Also, he experienced night sweats, decrease in appetite and intermittent fever usually in the afternoon.
Mr. S.B. sought immediate medical attention when suddenly he coughed out blood about ½ cup while playing basketball five (5) days prior to admission. He said that he really did not want to be admitted that’s why he did not consulted early. Initially, he went to Brent Hospital and consulted in outpatient department and had his laboratory exams done including Chest X-ray. Upon having the result, the doctor then advised him for admission so he immediately went back to Camp Navarro General Hospital. He is experiencing hemoptysis and difficulty of breathing progressively.