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Emergency Department - Practitioner Notes Registered Date of Service: 2/4/2008 3:29:00PM REASON FOR VISIT:The patient is registered by the clerical staff complaining of "lac." MODE OF ARRIVAL: The patient arrived by private vehicle.
HISTORIAN: The patient's history is gathered from the patient.
CHIEF COMPLAINT:Left upper extremity laceration HISTORY OF PRESENT ILLNESS:The patient presents for evaluation of a laceration to the left forearm occurring approximately 1 hour prior toarrival. There is minimal, associated pain. There is normal range of motion. There is normal distal neuromotorstatus without numbness or impaired movement. There is no foreign body sensation. There are no otherinjuries.
PAST MEDICAL HISTORY:Hypertension, hypercholesterolemia, diabetes mellitus Type II.
PAST SURGICAL HISTORY:Hysterectomy, appendectomy.
ALCOHOL: The patient does not consume alcohol.
DRUGS: The patient denies use of illicit drugs.
TOBACCO: The patient is a non-smoker.
GENERAL: well developed, well nourished, awake and alert.
SKIN: Laceration: Skin is warm and dry. There is a superficial, 5 cm. laceration noted on the volar aspect of EXTREMITIES: No joint effusion or cyanosis.
NEURO: Alert and cooperative. Sensory and motor functions grossly intact.
Pulse oximeter is 99 % on room air. This is interpreted as normal.
Registered Date of Service: 2/4/2008 3:29:00PM LACERATION MANAGEMENT: The wound was prepped with Betadine. Anesthesia was obtained using 1 % Wound closure: The wound was closed with single layer skin closure using 4-0 prolene. The patient tolerated the procedure well.
COORDINATION OF CARE: The nurse's notes were reviewed.
PRESCRIPTIONS:cephalexin, Dosage: 500 mg, Disp: -28-, Sig: 1 tab po QID, Refills: -0- Acute, left forearm laceration with simple repair.
DISPOSITION:LACERATION, EXTREM (SUTURE OR TAPE) DISCHARGE INSTRUCTIONS: FOLLOW-UP: Follow-up with your physician, Dr. Shaheen Iqbal for evaluation: Wound check in 2 days.
Suture removal 7 days.
LACERATION, EXTREMITYA LACERATION is a cut through the skin. This will usually require stitches if it is deep. Minor cuts may be treatedwith surgical tape closures ("Steri-Strips") or Dermabond Skin Adhesive.
HOME CARE:1) Keep the wound clean and dry. If a bandage was applied and it becomes wet or dirty, replace it. Otherwise,leave it in place for the first 24 hours, then change it once a day or as directed.
2) If sutures were used, clean the wound daily:After removing the bandage, wash the area with soap and water. Use Hydrogen Peroxide on a cotton swab (Q tip)to loosen and remove any blood or crust that forms.
After cleaning, apply a thin layer of Neosporin or Bacitracin ointment. This will keep the wound clean and make iteasier to remove the stitches. Reapply the bandage.
You may shower as usual after the first 24 hours, but do not soak the area in water (no baths or swimming) untilthe sutures are removed.
3) If a Steri-Strips tape closure was used, keep the area clean and dry. If it becomes wet, blot it dry with a towel.
After the Steri-Strips have been removed it is safe to resume your usual activities.
4) You may use acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) to control pain, unless another pain medicinewas prescribed. [NOTE: If you have chronic liver or kidney disease or ever had a stomach ulcer or GI bleeding, Registered Date of Service: 2/4/2008 3:29:00PM talk with your doctor before using these medicines.]However, an infection may sometimes occur despite proper treatment. Therefore, check the wound daily for thesigns of infection listed below. STITCHES should be removed within 7-14 days. If a TAPE CLOSURE("Steri-Strips") was used, remove them after seven days unless told otherwise.
RETURN PROMPTLYor contact your doctor if any of the following occur:Increasing pain in the woundRedness, swelling or pus coming from the woundFever over 100.0º F (37.8º C) oral, or over 101.0º F (38.3º C) rectalIf sutures come apart or fall out or if Steri-Strips fall off before five daysIf the wound edges re-openNumbness that does not go away by the time of suture removalCopyright 1990-2007 Parker Hill Associates, Inc.

Source: http://www.touchmedix.com/docs/Prac%20Chart.pdf

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