Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with an open wound to the right forearm sustained via [mechanism of injury] at [time]. Patient reports [pain level/characteristics], localized bleeding, and [presence/absence of numbness or paresthesia]. No reported loss of consciousness or distal neurovascular compromise.
Clinical Examination Findings
Right forearm inspection reveals a [length] cm laceration/avulsion located on the [anterior/posterior/medial/lateral] aspect. Wound edges are [clean/irregular/contused]. Active bleeding [controlled/ongoing]. Distal neurovascular status: radial pulse [intact/diminished], capillary refill <2 seconds, sensation intact to light touch in median, ulnar, and radial nerve distributions. Motor function intact.
Treatment Protocol
Wound irrigated with [volume] mL normal saline. Hemostasis achieved via [direct pressure/suture/staples/adhesive]. Wound dressed with [dressing type]. Tetanus prophylaxis [administered/up to date]. Prescribed [antibiotics/analgesics] as indicated.