PT:Doe, John
DOS:04/10/98
MR#:12345
ERMD:Roger Smith, M.D.
PCP:Dr. Brown
DD:04/10/98
DT:04/10/98
MS:f

HISTORY OF PRESENT ILLNESS:
This eight-year-old, otherwise healthy male, tripped and fell on some cement at school at 10:40 hours today. There is a laceration directly over the right patella.

ALLERGIES:
None.

CURRENT MEDICATIONS:
Proventil inhaler.

PAST MEDICAL HISTORY:
Asthma.

PHYSICAL EXAMINATION:
GENERAL: The patient is a well-nourished, well-developed, athletic-appearing, eight-year-old male. He is talkative and in no apparent distress.
VITAL SIGNS: Temperature 98.3. Respirations 20. Blood pressure 104/55. Pulse 92.
HEENT: Lids and conjunctivae are normal. Pupils are equal, round, and reactive to light.
EXTREMITIES: Examination of the right anterior knee reveals a flap-like laceration, which is distally based. The laceration is 2.0 cm on the side and about 5.0-6.0 mm across at the base. All but the 5.0 mm vertex portion of the flap has a deep tissue attachment and good vascularity.

EMERGENCY ROOM COURSE:
The wound is anesthetized using 1% lidocaine with epinephrine for anesthetic. It is quite dirty initially, but is scrubbed and irrigated until it is cleaned up quite nicely. No foreign body could be seen at the time of suturing. The laceration was approximated with a total of seven 4-0 nylon sutures.

ASSESSMENT:
1. RIGHT KNEE LACERATION.

PLAN:
The patient is given a posterior splint across his right knee. I felt quite strongly that the splint would be necessary to prevent traumatizing of the laceration repair, pulling out of the sutures. The wound should be reexamined in two days. The patient is to take Tylenol prn pain. Suture removal in 12 days. The splint should be used for one week.

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Roger Smith, M.D.