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PRESENT ILLNESS: This is about a 30 year old colored male admitted with body burns and several lacerations in a three day old injury to the left forearm. He relates he woke up, lying in bed at a lady friend's house on fire and ran out of the house and rolled in sand to extinguish the burns. On examination of the patient in the ER reveals body burns with the following approximate distribution. About one to three percent burns of the face and neck and ears involving the lips and tongue to a small degree as well as ears. About 18% of the anterior trunk, about 10-12% of the upper extremities, mainly of the arms and sparing the left forearm and both hands. About S% burn of portions•of_the genitalia including some of the foreskin and part of the perineum and the proximal medial thighs. There is also found a laceration of the right forehead apparently incurred at the Same time as well as a jagged, dirty, laceration of the right.hand on the dorsum -of the MP joint- of the ring finger. This reveals an exposed extensor apparatus which is about 75+ divided probably entering the joint. No particular matter is seen. There is swelling and marked tenderness and pain.at any motion of the left forearm and x-rays reveal this to be a fracture of the ulnaobliquely involving the distal ..one half or third and entering the wrist joint. This was incurred three days ago when the patient was injured in a football game. Initial treatment consisted of a cut down in the saphenous vein above the right ankle - with an 18 catheter and the administration of electrolyte fluids rapidly, cleansing of the burns, debridement of the burns, application of Silvadene Cream. Using local anesthesia the laceration of right forehead was cleansed*and repaired with several sutures of interrupted 5-0 Ethalon. The laceratzrn of the hand was anesthetized with local anesthesia and irrigated thoroughly with sterile saline and cleansed with Betadine solution and a single horizontal mattress suture of 3-0 Ethalon was placed to approximate the extensor apparatus and the wound was closed loselp with interrupted 4-0 Ethalon and a Xerofor.. antibiotic 4X4 Kling dressing applied just to the portion of the hand injured and a portion of the burns of the hand. The left forearm was treated with application of sheet wadding and Volar metal splint and an orthopedic consultation requested for the following day. A Foley catheter was placed. . PAST HISTORY: General health has been satisfactory. He admits to a hospitalization in 1969 and in Chatanooga, Tennessee for s:ab wounds with a 14 day hospitalization and an abdominal exploration though he knowsnct what procedure was done. He has had a snake bite in the past. Otherwise in good health. . F91ILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: s Essentially negative. Continued'. . • JUL 051�`� He denies any allergies. Dr. Signature 1467 _r Rsd.6/77 r�GK 5 FAQ — 2 f 6 0 dr MAL nv�a-� e Vero Beach, Florida . - - HISTORY ACID PHYSICAL • / . I[ - ' - • r. patient Name Mending Physidan Room No. .Hosp. No. : CARLTO-I, JORNTNY Or . M N''IYYRE, JOHN or Dr. John Terry CCU 11-28-03 PRESENT ILLNESS: This is about a 30 year old colored male admitted with body burns and several lacerations in a three day old injury to the left forearm. He relates he woke up, lying in bed at a lady friend's house on fire and ran out of the house and rolled in sand to extinguish the burns. On examination of the patient in the ER reveals body burns with the following approximate distribution. About one to three percent burns of the face and neck and ears involving the lips and tongue to a small degree as well as ears. About 18% of the anterior trunk, about 10-12% of the upper extremities, mainly of the arms and sparing the left forearm and both hands. About S% burn of portions•of_the genitalia including some of the foreskin and part of the perineum and the proximal medial thighs. There is also found a laceration of the right forehead apparently incurred at the Same time as well as a jagged, dirty, laceration of the right.hand on the dorsum -of the MP joint- of the ring finger. This reveals an exposed extensor apparatus which is about 75+ divided probably entering the joint. No particular matter is seen. There is swelling and marked tenderness and pain.at any motion of the left forearm and x-rays reveal this to be a fracture of the ulnaobliquely involving the distal ..one half or third and entering the wrist joint. This was incurred three days ago when the patient was injured in a football game. Initial treatment consisted of a cut down in the saphenous vein above the right ankle - with an 18 catheter and the administration of electrolyte fluids rapidly, cleansing of the burns, debridement of the burns, application of Silvadene Cream. Using local anesthesia the laceration of right forehead was cleansed*and repaired with several sutures of interrupted 5-0 Ethalon. The laceratzrn of the hand was anesthetized with local anesthesia and irrigated thoroughly with sterile saline and cleansed with Betadine solution and a single horizontal mattress suture of 3-0 Ethalon was placed to approximate the extensor apparatus and the wound was closed loselp with interrupted 4-0 Ethalon and a Xerofor.. antibiotic 4X4 Kling dressing applied just to the portion of the hand injured and a portion of the burns of the hand. The left forearm was treated with application of sheet wadding and Volar metal splint and an orthopedic consultation requested for the following day. A Foley catheter was placed. . PAST HISTORY: General health has been satisfactory. He admits to a hospitalization in 1969 and in Chatanooga, Tennessee for s:ab wounds with a 14 day hospitalization and an abdominal exploration though he knowsnct what procedure was done. He has had a snake bite in the past. Otherwise in good health. . F91ILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: s Essentially negative. Continued'. . • JUL 051�`� He denies any allergies. Dr. Signature 1467 _r Rsd.6/77 r�GK 5 FAQ — 2 f 6