Lacerations

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  •  HPI:
    • Characteristics obtain from interview with patient:
      • Quality of symptom:
        •  
      • Onset: 
        • acute, 
        • subacute, 
        • chronic, 
      •   Circumstances at time of onset:
        • pt unable to recall
      •   Since onset:
        • constant, 
        • intermittent, 
        • resolved, asymptomatic at this time, 
        • improving, 
        • worsening, 
      • Description of quality of symptom:
        • painful, 
          • sharp, 
          • dull, 
          • pressure, 
          • burning
      • Location:
      • Provocation:
        • none
      • Alleviation:
        • none, 
      • Associated symptoms
        • none
      • History of similar symptom is past
        • never
      • Outcome of symptom in past
      • History unfortunately limited
        • secondary
          • to patient"s condition, 
          • to requirement of emergent diagnostics/interventions that take precedence over extensive history, 
          • to patient"s lack of understanding of their medical conditions, 
          • to patient"s lack of cooperative with interview, 
          • to lack of medical records for this patient available in our system,
          • to lack of patient bringing medical information
    • Pertinent positives:
    • Pertinent negatives:
  • Time since injury:
      • <6 hrs
      • 6-24 hrs
      • >24 hrs
    • Location of laceration:
      • face,
      • ear,
      • hand, 
      • feet, 
      • leg, 
      • arm, 
      • chest, 
      • ear, 
      • lip, 
      • intra-oral, 
    • Pt denies bite as mechanism.
    • Pt denies bite as cause of laceration per pt,
      • bite by
        • human
        • animal
          • type of animal
          • accessed for risk of rabies
            • given animal able to be observed, was acting normally, and was provoked, and animal not animal known to have rabies in US, will have pt observe animal and if animal exhibits abnormal behavior, pt to have animal euthanized for evaluation for rabies and pt to return to ED immediately for rabies post exposure prophylaxis. 
            • given animal of type that has been known to have rabies in US, will administer rabies post exposure prophylaxis. 
    • Risk factors for infection during healing:
      • DM,
      • difficulty for pt to follow up, 
      • immunocompromised, 
      • etoh abuse, 
    • Tetanus status:
      • within 5 years per pt
      • >5 years though pt states was fully immunized as child
      • unknown if ever immunized
      • knows was not immunized 
  • ((+))
    • mod_ ReEval
    • mod_ Disposition
    •   Supplemental Aspects of Care:
      •   COUNSELING: To the extent that was possible, patient/family educated on diagnostics, assessment, treatment plan. Patient/family amendable and in agreement with plan. All questions and concerns answered and addressed.
      • Laceration Specific Counseling:
        •  I discussed the possibility of residual foreign body with patient and that no matter how thorough the search it is still a possibility. I explained to return if patient notices signs of retained FB.
        •  I also explained what to look for with regard to infection. The patient agreed to return with any increasing discharge, extending erythema, fever, nausea/vomiting or any other changes.
        •  I also discussed the inevitability of scarring with the patient. They understand that all lacerations will leave a varying degree of scarring and optimal outcome/cosmetic appearance can never be guaranteed. They also understand the possibility of prompt revision by plastic surgery if desired.
        •  Advised on follow up timing for suture removal.
      • COUNSELING: Attempted to explain and obtain patient’s approval for plan however unable to do so secondary to patient’s condition and the requirement of emergent evaluation and interventions.
      •  SUPERVISION: Evaluation, assessment, plan, and disposition discussed with attending physician who approves and is in agreement with evaluation, assessment, plan, and disposition. 
        • Attending MD  
      • PROCEDURE NOTE REGARDING REPAIR OF LACERATION
        • location of wound:
        • size of wound: cm
        • complexity:
          • simple
          • intermediate
            • given requirement for 
              • debridement, 
              • multiple layers of sutures, 
              • complex stitches, 
            • complex
              • given requirement for 
                • debridement, 
                • multiple layers of sutures, 
                • complex stitches, 
      •  Of note, radiology over-read mechanism in place for formal reads on imaging will hospital call back mechanism in place
  • Targeted exam to complaint:
    • location of laceration:
    • size of laceration: cm
    • neuro sensation intact at and distal to site of injury
    • vascular intact at and distal to site of injury
    • motor intact at and distal to site of injury  isolating areas around laceration and testing for strength
      • 5/5 throughout
      • 4/5 throughout
  • mod_ AP

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