Skin Wound
Age: years old
Gender:
HISTORY:
Presents with a laceration that occurred ago
Location is on
Mechanism of injury:
Alleviating factors: ,
Occupation:
Work-related injury:
Associated symptoms: *Try using right-click for negatives*
, up to °, over
Contributing factors:
no history of: ,
tetanus vaccination:
EXAM:
General appearance: ,
Skin: on
ASSESSMENT:
DDx: simple laceration, complex laceration, puncture wound, avulsion injury, tendon injury, nerve injury, vascular injury, animal bite, human bite, abrasion, crush injury, amputation injury, burn, foreign body in skin, cellulitis, tetanus, rabies
PLAN:
Investigations:
- X-ray if foreign body or fracture suspected
Laceration repair:
- Local anesthesia with cc
- Cleaning and irrigation with normal saline
- Exploration of wound
- Closure with
- Dressing with antibiotic ointment
Treatments:
-
-
-
- Tetanus vaccination
- Wound dressing
- Education on wound care
Further care:
- Referral to plastic surgeon for complex lacerations
- Suture removal in days
- Follow-up in for wound check
- Return if signs of infection develop such as redness, swelling, pus, or fever
HISTORY: Associated symptoms: EXAM: ASSESSMENT: PLAN: