PERSONAL DATA

Name: Mcdo

Address: #626 Antalasia, Enchanted Kingdom

Age: 26 y/o

Gender: Male

Civil Status: Single

Birth date: November 10,1983

Occupation: Businessman

Nationality: Filipino

Religion: Roman: Catholic

Admission: October 25,2009

Time: 7:31 pm

Discharged: November 4, 2009

Time: 10:00 am

Chief Complaint: Gun shot wound

Admitting Diagnosis: Gunshot wound, point of entry left subcostal area, point
of exit none

Final Diagnosis: Gunshot wound, point of entry left subcostal area, point of
exit none, Billroth 2 with peritonitis secondary to gun shot wound

Attending Physician: Dr. Andrew J. O’ Brien

HISTORY OF PRESENT ILLNESS

One hour prior to hospitalization, Mcdo and his girlfriend, Wendy, is

busy preparing their dinner which includes a couple of rice, shrimps, beef
steak and mouth watering desserts served on their astonishing table.

After such bountiful meal they clench their thirst with a red wine. Mcdo
and Wendy tried to get some rest at his bedroom.
 At around 7:00 in the evening Jollibee arrived and hurriedly looked for
Mcdo. Mcdo was surprised to see Jollibee. With Jollibee’s anger, he
unconsciously delivered multiple shots with his 45 caliber gun from a
distance of 4-5 meters aimed to Mcdo.

Wendy immediately rushed Mcdo to the nearest hospital (Crystal

General Hospital). As the clock hits 7:31 pm they arrived at the ER
department and were attended immediately with chief complaint of multiple
gun shot wounds.

At the ER, he was noted dyspneic and on distress, cold, clammy, with
clear breathe sounds, tachypneic, tachycardic. With Tender abdomen on all
quadrants, hypoactive bowel sounds; pulse is weak and thready double line
fast drip PLRS and PNSS. Dr. O’ Brien also ordered the following:

➢ Direct OR for “e” Explore Lap

➢ Secure consent
➢ Inform OR/AOD
➢ Secure 4 “u” PRBC
➢ Sulbactam + Ampicillin 1.5g IV now then 750 mg q8 ANST
➢ For CXR
➢ CBC typing STAT
➢ ABG
➢ PNSS 1L FD
➢ PLRS 1L FD
➢ IVF to follow: PNSS 1L X 12 hours
PLRS 1L X 6 hours

HISTORY OF PAST ILLNESS

Prior to hospitalization, Mcdo was diagnosed with peptic ulcer disease

by the year 2006 at the same hospital (Crystal General Hospital). A
medication such as Aluminum Hydroxide was prescribed to him and
eventually the symptoms he had, gradually disappeared. He was advised to
avoid acidic and spicy foods.

Aside from PUD, he had also incurred minor illnesses such as common
colds, cough and fever. He tried to relieve this condition by taking OTC drugs
such paracetamol, decolgen and solmux.

FAMILY HISTORY
 Mcdo’s family is composed of three members, his father, mother and
he. He claimed that hypertension runs in his patriarchal side and told us that
his grandfather died because of it. In his matriarchal side, asthma is present
to his aunts and cousins.

EMVIRONMENTAL HISTORY

He lives alone in a luxurious mansion with a pool nearby and a

beautifully landscaped garden located at the middle of a town. The nearest
hospital is 15-20 minutes away. Foods chains are meters away. Malls, spas,
gyms and other sports arena/clinics are nearby. He lives in a typical city.

SOCIOECONOMIC HISTORY

He is the heir of a business tycoon and a lawyer. He is the only child.

He graduated in a well-known school abroad and finished a degree in
business management. He is currently working in one of their companies as
a president for almost 2 years already.

LIFESTYLE

Although Mcdo is wealthy, he doesn’t smoke, he drinks liquor

occasionally, and he goes out with his friends on especial events and dines in
expensive restaurants together with the family and/or the clients only. The
only vice he have is playing poker with friends, also with clients in some
situations.