Name: Cint Ian Quinajon Address: 13 San Rafael Homesite, Tarlac City Date Admitted: April 19,2012 Diagnosis:

T/C Potts Disease T7 level History of Present Illness Present condition started 6 months prior to admission, when patient fell from a tree about 3-4 feet high landed on his low back fist. Patient was well right after the incident no weakness and numbness noted, no consult and no medication taken, patient was able to do his usual activities of daily living. Patient was apparently well until 4 months prior to admission, mother of the patient noted easy fatigability. Patient can still do his usual daily activities but played less outside and usually stayed at home.Patient also complained of getting tired easily when walking, there was also decrease in appetite noted and occasional low grade fever they also noted occasional buckling of right knee.They consulted a traditional faith healer,no consult to doctors and no medications taken.No bowel and bladder changes noted. 3 months prior to admission,there was persistence odf thw said symptoms.this time [patient had to drag his right lower extremity,but he can still ambulate independently and can still do his usual activities,no bladder and bowel changes noted.No back pain noted. During the interview, patient remained status quo, until 2 months prior to admission, there was progression of weakness of both extremities, patient started to have difficulty walking. Patient had to be assisted and had to hold on to furniture. Then 2 weeks after, patient also started to have difficulty maintaining standing pasture. Patient would usually spend his time at home lying supine or sitting down. One month prior to admission, patient consulted in a nearby medical mission and was advised to consult at a general hospital. He was just given Vit. B complex. During this time patient noted episodes of difficulty emptying bladder, patient started to have sensation that cannot fully empty bladder, no bowel changes noted. With persistence of symptoms 2 weeks prior to admission, patient consulted as out patient at Jecsons Medical Center where chest X-ray was done which showed electrolyte imbalance. Patient was then prescribed with Cefuroxime BID and was suggested to have MRI done. Patient took Cefuroxime for 3 days and was not able to do the MRI because of financial constraints, instead they decided to consult at a government hospital 1 week prior to admission, and they consulted at Central Luzon Doctors Hospital, where they were admitted. Thoracic X-ray was done and assessed to have Cord Compression, Upper Mid Thoracic, likely Potts disease, Pneumonia resolving. Patient was prescribed with INH 200mg/5ml, 10 ml OD pre breakfast, rifampicin 200mg/5ml, 12 ml OD pre breakfast, Pyrazinamide, 250mg/5ml,7ml BID and Streptomycin 700mg IVP OD, they also suggested MRI of thoracic spine and suggested transfer to a more specialized institution ,and advised to consult at Philippine Orthopedic Center. Patient was then discharged ad few hours prior to admission was transferred via a private car while sitting in a low back rest position without spinal support in our institution, hence this admission.

Past Medical History No history of PTB, asthma, heart or kidney disease, no previous hospitalization. At 9 months old patient underwent repair of hernia done in Central Luzon Doctors Hospital. Family History Patients grandmother on father side has diabetes and patients grandfather side has hypertension. No history of asthma, kidney disease, and cancer and heredofamilial disease. Immunization history The mother claimed that the patient had completed vaccination, given by the health center.