case study History of Present Illness

May 28th, 2015
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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.

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Name: V.O.AAddress: Brgy. S.J.B.BAge: 22 Years OldBirth date: August 05, 1988Birthplace: Brgy. S.J.B.BGender: MaleMarital status: SingleReligion: Roman CatholicEducational Level: College Graduate Occupation: Security GuardNationality: FilipinoPerson next to kin (optional): Mother and wifeAdmission Date: July12, 2011Admission Time: 1:55 AMArea of Admission: Female Surgical Ward.Attending Physician (initial): Dr. DAdmission 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): Patients 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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