Medical card: Vladimir Biryukov

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Name of medical organization: Central Military Hospital of Volgograd

MEDICAL CARD
OF PATIENT

First Name-Last Name: Vladimir-Biryukov
Date of birth: 22.01.796
Place of employment: Army Colonel, SCRA.
Place of residence: Planet Jiangxi, Square 26.
Date of admission: 02.08.835
Referral: Traumatologist.
Referral diagnosis: Traumatic, penetrating injury to the upper respiratory tract, unspecified 1st-3rd degree burns, coma of unspecified etiology. Condition stable but serious.
Wedge. Diagnosis: Pneumothorax, traumatic fragmentation of the laryngeal cartilage, fracture - damage to R.II, L.IV ribs. Penetrating injury in the cell area.
Complaints upon admission: None, the patient's condition is assessed as stable-serious.

ANAMNESIS MORBI: According to accompanying persons, on 28.06.835, the patient suffered multiple injuries as a result of an accident on the ship CPW-Smolensk. He was delivered to the department in a coma, in a cryocapsule, with signs of partial perfusion. ANAMNESIS VITAE AND EXAMINATION DATA: On 02.08.835, upon admission, the patient was sent to the intensive care unit. Objective status upon admission: BP 106/45 mm Hg, signs of local hypotension. Oxygen saturation (SpO2) below 87% (86.5%) – signs of hypoxia. Heart rate 48 beats/min. Mucous membranes are cyanotic, hyperemic, with signs of dystrophy. Pupils' reaction to light is sluggish, with a delay of 0.5 seconds. Light sensitivity preserved, no areflexia detected. Chest skin damaged, evidence of intrapleural hemorrhage. Initial treatment administered to stabilize condition. Chest X-ray ordered. Examination results: • Chest X-ray (02.08.835): In the area of the second right rib, there is a comminuted fracture with perforation of the right lung tissue (S2). Heterogeneous formations resembling blood clots (red/white thrombus) are detected in the pleural cavity. Signs of pneumothorax were detected. In the area of the IV left rib, there is a crack with transition to the intercostal vessels. • ECHO-KG, abdominal ultrasound (03.08.835): No pathology. • EEG (03.08.835): There is a decrease in the overall bioelectrical activity of the brain. Delta rhythm predominates, alpha rhythm is preserved. • MRI of the brain (04.08.835): Stage I epidural hematoma detected. TREATMENT AND DYNAMICS OF THE CONDITION: 02.08.835 An occlusive dressing was applied to the pneumothorax area, against which background intrapleural pressure normalized. Oxygen saturation (SpO2) increased in proportion to the decrease in pressure. 03.08.835 at 02:05 ventricular fibrillation was recorded. Heart rate – 176 beats/min, blood pressure 200/130 mm Hg. Defibrillation was performed, a solution of levomenthol was administered. Fibrillation was stopped, heart rate stabilized. SpO2 stable at 90%. Chest surgery was prescribed with suturing of lung tissue using non-absorbable atraumatic suture material. 03.08.835 10:05: Thoracotomy performed, primary surgical treatment of the wound, suturing of the lung and pleural defect (Lambert suture), osteosynthesis of rib fractures with a titanium plate. Intraoperatively, the patient's condition is stable. Course of the operation: Treatment of the surgical field with iodine solution. Primary surgical treatment of the wound. An incision was made in the parasternal area of the third rib. Bone fragments were removed. Suturing of the visceral pleura with a catgut suture using a Lambert suture with an atraumatic needle. Fixation of fragments with sulfacrylate with the application of a titanium plate and bone screws. Layered suturing of the wound. Aseptic treatment of the postoperative wound with application of a bandage. An additional incision was made in the area of the fourth left rib, the fracture was fixed with bone wax, and the wound was sutured using a Lambert suture. The patient's condition during the operation was stable, with no abnormalities noted. - - -

Secondary sheet: 03.08.835 Tests were performed: complete blood count, urinalysis, blood test for lipid profile (lipidogram), proteinogram, C-reactive protein, ECG cardiogram, abdominal ultrasound, encephalogram. 04.08.835 The patient's condition improved: consciousness was restored after a comatose state with elements of stupor. Pupil light sensitivity is normal, reflexes are preserved. A decrease in cognitive functions is noted. An MRI of the brain was prescribed to rule out focal pathology. Surgical drainage of fluid from the epidural cavity of the brain and restoration of the parietal venous sinus of the brain have been scheduled. 04.08.835 12:05 Drainage of the epidural hematoma has been performed. The operation was completed without complications. 04.08.835 Mucous membranes are pink and moist. No signs of dystrophy observed. Postoperative wound in the chest area with bandage, healing by primary tension. Condition of skin around the wound is satisfactory. Therapy prescribed: intravenous vasodilators — 1 dose/day, 300 ml; neurotrophic drugs — 3 tablets/day; antihistamines; heparin. 12.08.835 The patient was transferred from the intensive care unit to the trauma unit. Condition stable, relatively satisfactory. Initial treatment plan: daily dressings until complete healing of the chest area, asepsis of burn areas. Referral to a neurologist. Training procedures prescribed to restore leg tendons. 15.08.835 The patient was prescribed rehabilitation procedures (physical training, visits to specialized exercise machines). A medical examination was conducted. The condition is assessed as stable and simplified. 25.09.835 The patient's condition is stable. Neurotrophic drugs have been discontinued. - - -