WHO is a 49 year old female, single, Roman Catholic, from Fresco, Guenon City, admitted for the first time in Philippine Orthopedic Center on July 26, 2013.
Informant is the patient herself with good reliability. Chief Complaint: Left Foot Pain l. SUBJECTIVE A few hours prior to consult, patient was about to go home and was seated when a colleague accidentally pulled the trigger of a mm caliber from 5 feet away, hitting her left foot. Patient was brought in General Hospital and was referred to thePhilippine Orthopedic Center for further management, thus prompting consult. ROSS (-) fever, despise, nausea and vomiting PM: (-) HIP, DMS, asthma, blood dysphasia (+) allergies to seafood and chicken Surgery for intestinal obstruction (2010), Appendectomy (2007) Review of current medications: None Present Labs done: x-ray, wound gram stain, blood typing Vaccinations Patient was given an anti-tetanus shot and tetanus toxic upon arrival in the POCK RE Family History unremarkable . Personal/ SocialPatient is currently a security guard in the ASS Compound. She is single and she lives with 1 1 other household members (siblings, nieces, nephews) in a bungalow house in Fresco. She is a non-smoker and non-alcoholic.
Stake holder analysis Patient is single and takes care of her own medical bills. She is also the primary decision maker and financier when it comes to matters involving her health. Her 2 younger sisters are her caretakers. II. OBJECTIVE General: Patient is awake, stretcher-borne, coherent Vitals:Height: 5’4″ Weight: 58 keg, HER: 78 beats/min, OR: 20 breaths/min, Temp: 36. 0 C BP: 120. 80 HEN: (-) Cervical lymphocyte’s Pale Palpable Conjunctiva no oral and nasal lesions and deviations Cardiovascular: Chest and Lungs: Clear breath sounds, resonant on percussion in all lung fields Abdomen: Normative bowel sounds, no tenderness or masses upon palpation, no bruits Musculoskeletal: XIX CM wound on the lateral aspect of the left foot No gross hematite Left Ankle: (+) swelling tenderness upon palpation (+) limitation of movement in the ankle due to painNumbness in the left lateral aspect of the foot Symmetrical pulses (dorsal piped, posterior tibiae) Ill.
ASSESSMENT A. Problem List: Gunshot wound, Pain and swelling, Patient not ambulatory B. Primary Impression: Gunshot Wound, Left Lateral Aspect of the Foot A gunshot wound is a penetrating wound that can damage soft tissues and can result to fractures and infection. Damage can be caused by the passage of missile, secondary shock wave or cavitations. The gunshot caused by the mm caliber pistol was classified as low velocity (