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case study History of Present Illness

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Name: V.O.A
Address: Brgy. S.J.B.B
Age: 22 Years Old
Birth date: August 05, 1988
Birthplace: Brgy. S.J.B.B
Gender: Male
Marital status: Single
Religion: Roman Catholic
Educational Level: College Graduate
Occupation: Security Guard
Nationality: Filipino
Person next to kin (optional): Mother and wife
Admission Date: July12, 2011
Admission Time: 1:55 AM
Area of Admission: Female Surgical Ward.
Attending Physician (initial): Dr. D
Admission Diagnosis: Internal Hemorrhage, Hemothorax Right Secondary to Gunshot.
( Special Procedure: Chest Tube Thoracostomy insertion.)
Principal diagnosis: Gunshot wound right chest area.
Sources (Primary/secondary data): Patient’s chart, Mother, Wife.
A. Chief Complaint:
Gunshot wound at the right chest area 30 minutes prior to confinement.
B. History of Present Illness:
30 minutes prior to confinement client V.O.A was on duty as a security guard in a restaurant. At
around 1:20am when another fellow guard from another establishment was chasing an enemy and the
other guard fired a warning shot.
At the moment client V.O.A heard the gun fire and rushed to the scene to check out what was
going on when suddenly the other guard fired another shot and client V.O.A got hit, when he was shot
at the right chest then he was brought to the RMPH by the bystanders at the scene. He was then
brought in the ER,

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he was assessed by the nurse on duty and his vital signs are: T- 36*C, PR-76bpm, RR-26cpm, BP-
90/60mmHg. Under the supervision of Dr. D. and after the assessment he was then brought to operating
room.
C. Past Health History:
V.O.A had experienced common fever, cough, cold, measles, mumps, and chicken pox.
Whenever he had fever he takes over the counter drugs such as paracetamol 500mg 1 tablet and
Neozep 1 tablet until it subsides.
He was been hospitalized in the year 2006 due to high fever at R.M.P.H under the service of Dr. M. He
was received complete immunization. He has no known allergies to food, drugs and Environmental
allergens.
D. Family History:
V.O.A is the third child among the fourth siblings. He has a live-in partner and they have one
child, his child is in a good health condition. His father and mother are alive and well. There is no
heredo-familial disease on both of his maternal and paternal side such as diabetes, asthma,
hypertension as claimed by his mother.
GENOGRAM
E. Psychosocial History
V.O.A is the third child in the family. He lives together with his live-in partner and daughter. He
usually wakes up at around 5AM and sleeps at around 9PM. He usually spends his time playing with his
daughter and playing Basketball as his usual hobby.
He is kind and conversant to his neighbor. He has a harmonious relationship with his neighbor and no
known enemy as verbalized by his mother. He has a positive outlook in life as he claimed.
Patterns of living:
1. Health practices and belief/ self care activities: whenever he feels sick he takes over the counter
medication such as Paracetamol and Neozep. He believes that through exercise he will remain healthy.
2. Typical day: He usually takes a nap every afternoon. He loves to play with his daughter on the day of
his day off and going out with his live-in partner. At the Hospital he spends most of his time lying on the
bed due to his Chest Tube Thoracostomy (CTT).
3. Nutritional patterns: He has a good appetite and able to consume the food that was served to him.
He eats three times a day as claimed by his live-in partner. He has an IV fluid and NPO during
hospitalization.
4. Activity/exercise patterns: He usually plays basketball in their backyard as a form of exercise and
spent most of his time chatting with his friends.
5. Recreation, pets, and hobbies: He loves to play basketball with his friends in their house backyard.

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Name: V.O.A Address: Brgy. S.J.B.B Age: 22 Years Old Birth date: August 05, 1988 Birthplace: Brgy. S.J.B.B Gender: Male Marital status: Single Religion: Roman Catholic Educational Level: College Graduate Occupation: Security Guard Nationality: Filipino Person next to kin (optional): Mother and wife Admission Date: July12, 2011 Admission Time: 1:55 AM Area of Admission: Female Surgical Ward. Attending Physician (initial): Dr. D Admission Diagnosis: Internal Hemorrhage, Hemothorax Right Secondary to Gunshot. ( Special Procedure: Chest Tube Thoracostomy insertion.) Principal diagnosis: Gunshot wound right chest area. Sources (Primary/secondary data): Patient’s chart, Mother, Wife. A. Chief Complaint: Gunshot wound at the right chest area 30 minutes prior to confinement. B. History of Present Illness: 30 minutes prior to confinement client V.O.A was on duty as a security guard in a restaurant. At around 1:20am when another fellow guard from another establishment was chasing an enemy and the other guard fired a warning shot. At the moment client V.O.A heard the gun fire and rushed to the scene to check out what was going on when suddenly the other guard fired another shot and client V.O.A got hit, when he was shot at the right chest then he was brought to the RMPH by the bystanders at the scene. He was then brought in the ER, he was assessed by the nurse on duty and his vital signs are: T- 36*C, PR-76bpm, RR-26cpm, BP-90/60mmHg. Under the supervision of Dr. D. and ...
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