Extracted text

OCR Page 1 of 4
Truman, Harry S. Wallace H. Graham This patient was admitted to the hospital after having suffered a fall in the bathrwom, upon entering it. He states that he stepped into the room with his left foot, slipped and fell striking the right side of his head in the area of the eyebrow. He states this occurred approximately 1:45 p.m., he believes that he actually slipped as there was a step down and the rug in the bathroom had slipped prior to his fall. However, there is some question in my mind whether he stumbled, slipped or had a sudden blackout, and he is not absolutely sure at that. He struck the wash stand on the left side of his face, he stated he did not feel this blow, nor was he actually aware of falling. Then he fell against thebath tub at the right side and striking the right cheek. Then injuring his left chest also. He sustained a crushing injury with two deep lacerations and approximately 5 cms. in length over the orbital ridge, right side. These lacerations were in- ferior and through the right eyebrow and then immediately in the upper eyelid. There was a heavy ecchymosis with swelling right periorbital, laceration left cheek, also preauricular. He has considerable pain throughout the left chest and with considerable ecchymotic areas in the left thorax. These lacerations in the right upper lid were cleansed thoroughly, was performed and the brow was sutured with 4-0 chromic deep muscular suture bringing the muscles into ap- position and 5-0 Nylon sutures were then placed in an inter- rupted fashion for skin apposition and closure. This was done under local anesthesia and Nesacaine 28. He had no other complaints, he has had no cough or chest pain, any physical difficulties prior to hospital admission and he has had occasion- al minimal vertigo in the mornings usually when he arises from bed, he states. His general historyis that he wears corrective lens for certain type of axis deviation he has. He must wear one set for hyper- opia and then he wears another one for myopic change. He has occasional ringing in the ears and headaches to a minimal ex- tent, but when he reads long hours the headaches are particul- arly noted. His general history otherwise is essentially within normal limits. Family History: Mother died following fracture of the hip age 95 and following secondary infection with decubitus ulcers. The back also had considerable heavy arteriosclerosis with arteriosclerotio heart disease. Continued: NARA

Relations