Clinical note · #63
Procedures & modifiers
Patient: John Doe · Date of service: 09/11/2024
Chief complaint
Laceration on left forearm after a fall.
History of present illness
The patient presents with a 3 cm laceration on the left forearm that occurred 2 hours ago. The wound is jagged, and the patient reports moderate pain. No signs of infection or foreign bodies. The patient denies any previous incidents like this or significant medical history related to bleeding disorders. The patient had an updated tetanus shot within the last 3 years.
Review of systems
Denies any headache, dizziness, or other systemic complaints.
Physical exam
The patient is alert and oriented, no distress. The laceration is on the left forearm, measuring 3 cm, and extends through the dermis. There is mild bleeding. The surrounding skin shows no signs of infection. Neurological and cardiovascular exams are within normal limits.
Medical decision making
The decision was made to repair the laceration. Moderate complexity of care was required, considering the need for local anesthesia and layered closure. The patient was advised about the procedure, potential complications, and care after the repair. Consent was obtained.
Procedure
The area was cleaned and anesthetized using 1% lidocaine. A 2-layer closure was performed with 4-0 Vicryl for the deep layer and 5-0 nylon for the outer skin layer. The wound was dressed with sterile gauze. Post-procedure care instructions were given, including keeping the area clean and dry, monitoring for signs of infection, and follow-up in 10 days for suture removal.
Assessment / plan
- Laceration repair.
- Instructions on wound care and follow-up provided.