Short Study File #50
Note: Translation of document following scanned page
Note from Christina Masewicz: Translation of the above document as I read it to be
The part marked above is bold in the translated copy
HISTORY OF THE PRESENT ILLNESS: This 26-year-old, white mail was attacked in his home by unknown assailants at approximately 4 a.m. on the day of admission. He sustained a blow to the head and multiple small stab wounds.
PAST MEDICAL HISTORY: Noncontributory.
PHYSICAL EXAMINATION: This is a well-developed, well nourished male in moderate distress. Blood pressure - 128/70. Pulse - 88. HEEN - swelling and hematoma in the midline on his forehead. Dried blood around the mouth. Eyes - pupils were, regular and reactive to light and accommodation. Chest symmetrical; 1 cm stab wound in the 6th intercostal space in the midclavicular line; - decreased breath sounds on the right; no rales or rhonchi. Abdomen - several superficial lacerations, not extending into the subcutaneous tissue; also several small puncture wounds that may have been from an instrument, such as an ice pick. Abdomen was soft with no rebound. Bowel sounds were active. External genitalia - within normal limits. Extremities - full range of motion.
LABATORY DATA: Hematocrit - 43%. White blood count -12,647 with 83 segs, 17 lymphs. Urinalysis - within normal limits. Chest X-ray - 20% right pneumothorax on admission; 17 Feb 70 - chest X-ray showed chest tube in 7th intercostal space with persistent 20% pneumothorax on the right and no infiltrates or gross effusion. 18 Feb 70 - right angle chest tube in 2nd intercostal space; lower chest tube removed and lung remained well expanded; minimal blunting of right costophrenic angle. 23 Feb 70 - minimal pleural effusion on the right; re-expansion of right middle lobe; lungs clear; heart, mediastinum and bony thorax remain within normal limits.
HOSPITAL COURSE: Following admission, the patient was taken to the Intensive Care Ward where a # 36 argyle chest tube was inserted in the 7th intercostal space in the midclavicular line and attached to low Gomco suction. The tube could not be passed to the apex and the upper and middle lobes did not expand well. Therefore,