Situation: A twenty -year old man was found supine on Thompson Creak Trail (really nice. in Claremont) with a bullet wound. The entrance of the wound was on the left lateral side 1 cm above the third rib. The exit wound was 5 cm above the belly button in the umbilical region. while tracing the bullet path you notice at the entrance the bullet travels in the frontal plane with a 45- degree downward angle. On inspection of the right side of the rib cage by x-ray you observe the 8th rib fractured. Fragments of the bullets are then traced to the final exit wound. What is the leading differential diagnosis (and why) and what are three plausible alternatives and how would you rule them out?
Leading Differential Diagnosis: The man was killed due to internal bleeding and extensive damage to the heart, which was punctured by the bullet as it bounced off the 8th rib and exited out above the belly button.
Alternatives:
1. The bullet punctured both lungs creating a hole in both. This causes air to enter the body through the entrance wound, causing a change in pressure, and thus the lung collapsing. New air is not allowed to enter the lungs, causing shortness of breath and eventually death. You could rule this out because of the fact that the bullet exited 5 cm above the belly button, meaning it would be improbably that they bullet punctured both lungs.
2. The bullet punctured the stomach and small intestines, causing a serious infection from fecal matter leaking out into the body. Also death from extensive bleeding.
3. The bullet hit the 8th rib, bounced to the spinal chord, broke it, and then back out through the belly button. The man then continued to bleed internally and externally.
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