History of Present Condition

Patient sustained a 10 foot fall
Diagnosed as having:
1. Right-sided pneumothorax
2. Right sided fractured ribs
3. Right-sided sternoclavicular joint dislocation
4. Four centimeter scalp laceration.

Immediate Course of Action: Day #1
Patient came in to the ED following a fall. He was subject to chest x-rays, CT scan (head, chest, abdomen, pelvis, and cervical spine), as well as an MRI (lumbar, thoracic, and cervical spine). As stated above he was diagnosed as having a right-sided pneumothorax, multiple rib fractures, and a sternoclavicular joint dislocation.
  • To treat the pneumothorax he had a chest tube inserted with 20cm dry suction water-seal drainage ordered. The patient endured no complications as a result of this procedure.
  • To treat the dislocated joint he had his arm placed in a sling to stabilize the sternoclavicular joint.
  • The scalp laceration was closed with staples.
  • For his pain the patient had a thoracic epidural placed (10mg Dilaudid, 2mL q4min).

Course of Action: Day #2 Patient received another chest x-ray to monitor the status of the chest tube placement and pneumothorax. Results showed that the right lung had reexpanded. Patient also went in to atrial fibrillation with rapid ventricular response. He was placed on a Cardizem drip to maintain a HR of greater than 120 and SBP greater than 90.

Course of Action: Day #3 Patient received another chest x-ray to monitor the status of the chest tube placement and pneumothorax. Results showed that the right lung remained fully expanded. He also converted back to normal sinus rhythm at 2200.

Course of Action: Day #4 Patient received another chest x-ray to monitor the status of the chest tube placement and pneumothorax. Results showed that the right lung remained fully expanded, however there was increased opacity of the LLL suggestive of pneumonia. Patient was placed on Levaquin (750mg every 24 hours x 5 days).

Course of Action: Day #5-10 Patient's lung remains reexpanded. Copious amounts of drainage collected in water-seal system. He also completed his round of IV antibiotics for the pneumonia.

Course of Action: Day #11 Patient's chest tube removed as well as the staples from his scalp laceration.

Course of Action: Day #12 Patient was dismissed home. Went home with sling for his arm to stabilize the sternoclavicular joint.