Skin – LAC | CLINIBORG

HISTORY: provided by patient SO/family member present during visit chaperon/MA present during visit interpretation provided by family member/SO interpretation provided by MA complete history unobtainable d/t poor effort/affect complete history unobtainable d/t affect complete history unobtainable d/t language skills

CC: cut wound

LOCATION:

STATED CAUSE:
MVA fall assault sports injury work injury fall direct blow blunt trauma crush incision laceration jam

HPI: less than six hours ago less than 12 hours ago more than 12 hours ago one day ago more than one day ago no loss of sensation full range of motion of involved body part tingling loss of sensation distal to injury distal pallor/cyanosis distal weakness bleeding ceased bleeding minimal bleeding profuse bleeding controlled with pressure bleeding continues

PMSH: head injury previous injuries chronic pain meds diabetes PAD immunosuppression

TETANUS: up to date less than five years ago 5-10 years ago greater than 10 years ago unknown

REVIEW OF SYSTEMS: negative except as stated in HPI
General:

HEENT:

CV:

Pulmonary:

GI:

GU:

MSK:

Neurologic:

Psychiatric:

Endocrine:

Hematologic/lymphatic:

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General: well-appearing normal built heavy built muscular lean well-nourished emaciated frail no signs of discomfort visible while sitting in chair no signs of discomfort visible while ambulating and getting on/off exam table ill-appearing tired-looking short of breath diaphoretic good hygiene disheveled bizarre clothes body odor drowsy appears impaired slumped no ambulation aids/DME ambulation requires walker ambulation requires cane ambulation requires wheelchair wearing cervical collar wearing lumbar support wearing extremity brace

Head/Face: normocephalic, atraumatic symmetrical face CN grossly intact plethoric face alopecia facial droop

Eyes: clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus visual acuity grossly intact cornea clear glasses contacts conjunctival injection epiphora conjunctival exudate allergic shiners dysconjugate gaze

Ears: symmetrical and intact auricles bilaterally hearing to conversation intact clear canals without erythema or discharge TMs normal in appearance

Nose: nares patent bilaterally septum midline no facial tenderness mucosa pink and moist swollen and boggy mucosa mucosal congestion clear discharge yellow discharge crusty discharge rhinophyma

Mouth/Troat: normal voice, no stridor tongue normal in appearance w/o lesions and with good symmetrical movements moist oral mucosa without lesions patent pharynx w/o swelling or exudates uvula midline upper denture lower denture poor dentition oral ulcers gum swelling tooth decay hoarseness vesicles on soft palate petechiae on soft palate pharyngeal erythema w/o exudates

Neck: symmetric with free painless ROM and no masses supple no LAD no bruit or JVD anterior LAD posterior LAD thyroid enlargement nuchal tenderness

Chest/Lungs: normal work of breathing, symmetrical chest expansion clear and equal breath sounds bilaterally chest wall atraumatic and non-tender no axillary or supraclavicular LAD SOB decreased bilaterally wheezing crackles

CV: regular rhythm no murmurs no ankle edema pedal skin warm with good and equal pulses tachycardia irregular heart rhythm systolic murmur calf tenderness ankle edema varicosities stasis discoloration

Abdomen: normal visual inspection, no distension normal active bowel sounds soft non-tender no bruit auscultated over AA and renal arteries protruding surgical scar umbilical hernia diffuse tenderness over entire abdomen w/o RRG hypoactive bowel sounds hyperactive bowel sounds direct non-rebound tenderness colostomy in situ deferred

GU: no suprapubic tenderness no CVAT bilaterally Foley in situ normal external genitalia no inguinal LAD testicular tenderness urethral discharge verrucous papules vesicles crusted lesions deferred

MSK: no gross deformities, moves all extremities with good ROM for age full weight-bearing normal curvature and ROM in C- and L-spine for patient age strength, tone, and bulk symmetrical and grossly intact non-tender C-spine with good ROM paraspinal muscle spasm C-spine tenderness and DROM neck pain with active motion paracervical muscle spasm old surgical scar in C-spine trapezius tenderness kyphosis non-tender L-spine with good ROM paraspinal muscle spasm L-spine tenderness reduced painful ROM in lumbar region trigger points in L-spine old surgical scar in L-spine heel-walk and toe-walk without difficulty negative seated SLR positive seated SLR

Neuro: normal concentration and attention memory grossly intact balance and coordination grossly intact ambulates w/o limp or alteration in gait extremities strong w/o atrophy no gross motor deficits sensation symmetrical and grossly intact no involuntary movements or tremor antalgic gait wide gait shuffling gait diffuse numbness w/o dermatomal pattern dystonia tardive dyskinesia tics

Speech/Vocalization: normal for age clear and coherent slurred mumbling to self monotonous stuttering hypoverbal hyperverbal shouting high pitched loud soft slow rapid pressured groaning sighing crying perseveration flight of ideas repetitive questions self-depreciating statements repetitive statements of impending doom repetitive non-health related/financial concerns personal safety concerns suicidal ideation/threats requesting particular medication, test, referral, or accommodation raising voice defensive argumentative cursing, swearing providers/staff criticisms verbal threats sexual remarks racist remarks

Behavior/Psychomotor Activity: calm, pleasant, respectful cooperative with history and exam engaged good eye contact guarded anxious irritable frustrated labile agitated hostile forceful threatening gestures aggressive posturing pacing not sitting down fidgeting picking skin twirling hair cracking knuckles frequent hand gestures grimacing, frowning tightening jaw breathing hard fist-clenching intense staring subdued withdrawn constricted affect bradykinetic indifferent appears to be responding to internal psychotic process

LOCATION: left right first second third fourth fifth proximal distal medial lateral dorsal ventral

LENGTH: <2.6 cm 2.6–5.0 cm 5.1–7.5 cm 7.6-12.5 cm 12.6-20.0 cm 20.1-30.0 cm >30.0 cm

DEPTH: superficial subcutaneous muscle penetrating

SHAPE: linear curvilinear jagged flap stellate puncture

SURROUNDING SKIN: swollen abrasions ecchymosis

NVT: sensation (simple touch) intact normal capillary refill/pulses demonstrated FROM against resistance

OFFICE X-RAYS:

not indicated essentially normal no fx no FB staff to notify patient once radiology report becomes available

PLAN OF CARE: POC risks/benefits/alternatives discussed with patient/parent/SO, opportunity provided to ask questions verbalized understanding that X-rays reviewed online not diagnostic quality verbalized understanding that normal X-rays do not exclude non-displaced fracture verbalized understanding of and agreement with POC, discharge and f/u instructions did not agree with my POC/recommendations – will seek second opinion/further care elsewhere

CLOSURE: simple: single layer, no debridement intermediate: deep layers or single layer with debridement

SKIN PREP: restrains used skin cleaned with wound cleanser skin cleaned with hibiclens skin cleaned with Betadine draped in normal sterile fashion

ANESTHESIA: topical LET EMLA dig block local infiltration lido 1% lido 2% with epi with bicarb

PROCEDURE: wound explored debridement not required debridement required foreign material none visible foreign material minimal foreign material moderate foreign material extensive no tendons visible tendons appear intact foreign material removed partially foreign material removed completely wound irrigated with plenty of NS subcutaneous/submucosa closure achieved with several absorbable sutures skin closed with wound adhesive/Dermabond skin closed with strips/Steri-Strips skin closed with staples skin closed with simple sutures skin closed with continuous suture skin closed with vertical mattress skin closed with horizontal mattress wound-edge approximation achieved wound left open bleeding insignificant stopped with pressure covered with non-adherent dressing applied bulky gauze dressing NVT reassessment intact good hemostasis splint/brace applied limb elevated w/ sling patient tolerated procedure well

SKIN CLOSURE MATERIAL:
Brand:

Size:

Quantity:

RX: none electronic paper given to MA to be transmitted to pharmacy

REVIEWED: MA notes med list previous visits PMP/CURES previous laboratory/diagnostic studies/specialty reports hospital discharge

VERBALLY INSTRUCTED ON: vital signs/exam findings/recommendations x-ray findings keeping wound dry changing dressing when soiled/soaked at least daily cleaning area with soap and water after 24 hours and covering with non-adherent dsg applying petrolatum or another OTC product after 7 days to minimize scarring applying sunscreen on affected area to minimize scaring checking for N/V integrity of affected part returning to clinic or contacting emergency services for increasing pain, swelling, redness, drainage, fever contacting emergency services for NVT compromise controlling chronic conditions

BARRIERS TO CARE: language barrier socio-cultural factors poor effort/cooperation with exam incomplete history history not supported by findings vague complaints supporting documentation unavailable failed to obtain old records failed to complete referrals or testing multiple comorbidities polypharmacy multiple providers/prescribers intolerance of/allergty to/therapeutic failure on multiple meds frequent ER/UC visits frequent office contacts poor compliance with POC negative attitude to proposed tx lack of interest in non-drug tx overreliance on short-acting meds overwhelming focus on Rx drugs poor insight lack of motivation dependent attitude preoccupation with illness unhealthy coping mechanisms somatization catastrophization pessimism overgeneralization unrealistic health beliefs psych comorbidity anxiety depression alcohol or substance use social or occupational dysfunction secondary gain hostile/disruptive behavior affect none noted at this time

DISPOSITION:
RTC as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or NVT compromise RTC 24 hours RTC 48 to 72 hours RTC 1 week referred to burn center for further management referred to ER for immediate treatment via 911 referred to ER for immediate treatment via private transport declined emergency transfer left facility before being discharged asked to leave clinic

Skin – LAC

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