Chapter 2: The Integumentary System | Bennett Meira's Chart Note

CHART NOTE

Patient Name: Meira, Bennett
ID Number: 94421
Examination Date: February 20, 20xx

SUBJECTIVE
Patient is a 19-year-old male who was brought to FedDes Urgent Care by friends. He states that he was "knifed" due to a dispute over the outcome of a pool game. He has contusions to the abdomen and forehead and a stab wound of the right thigh. His tetanus is up to date. No other injuries. Denies any allergies and is not on any medications.

OBJECTIVE
Patient has a 2.5-cm vertical laceration of the lateral aspect of the right thigh that goes through the epidermis, dermis, and subcutaneous tissue down to the vascular layer of the thigh muscles. There does not appear to be any muscle injury, and there is no active bleeding, so no muscular tissue repair is necessary. Ecchymosis of the lower right anterior abdomen. Small hematoma of the forehead.

ASSESSMENT
Laceration, right lateral thigh.

PLAN
Suture repair and dressing applied. Wound care sheet given. Patient to return in 8 days for suture removal or earlier if signs of infection occur. He can use ibuprofen for pain. He was released in stable condition.