Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with an open wound to the left forearm sustained via [mechanism of injury] at [time]. Patient reports [pain level] pain, localized bleeding, and denies numbness, tingling, or distal motor deficits. No history of recent tetanus vaccination.
Clinical Examination Findings
Left forearm examination reveals a [length] cm laceration located on the [anterior/posterior/medial/lateral] aspect. Wound edges are [clean/irregular/contused]. No exposed bone, tendon, or neurovascular compromise noted. Capillary refill < 2 seconds. Distal pulses (radial/ulnar) 2+ and symmetric.
Treatment Protocol
Wound irrigated with [volume] mL normal saline. Hemostasis achieved via [direct pressure/sutures/staples/adhesive]. Wound dressed with [dressing type]. Tetanus prophylaxis administered [if indicated]. Patient advised on wound care and signs of infection.