Procedure Note
Name: John Doe
DOB: xx-xx-1978
Date: 10/5/2012
Preoperative diagnosis: 4 cm laceration to anterior proximal tibia
Postoperative diagnosis: Wound closure of 4 cm laceration to anterior proximal tibia
Procedure: Wound closure with ethilon sutures
Performed by: Alyson Wattai, PA-S/Dr. Robert Supplee (supervising)
Referring physician: Dr. Kreider (Family Physician)
Anesthesia/sedation: 4 cc 2% Lidocaine with epinephrine for local anesthesia
Preparation made for wound exploration, local anesthesia and wound closure in ED. Wound
closure to be performed to reduce risk of infection and prevention of significant scarring. Verbal
consent obtained from patient. Local anesthesia to be injected to numb wound area on anterior
proximal tibia.
Description of procedure and findings: 4 cm full-thickness (5 mm) laceration to anterior
proximal tibia. M/N/V intact. The procedure of local anesthesia and wound closure with sutures
was explained to patient. Also risk of secondary infection and benefit of scar reduction with
wound closure was disclosed to patient. Verbal consent was obtained from patient. Wound
irrigated with 1 L NSS. The field was prepped using standard sterile technique. Open wound area
cleaned with betadine scrub. Local anesthesia achieved with 2% lidocaine with epinephrine
approximately 4 cc. Wound explored with no foreign body present, no tendon involvement.
Successful closure with 4.0 ethilon x 4 simple interrupted sutures. Wound dressed with
Bacitracin and dry sterile gauze.
EBL in milliliters: Approximately 3 cc blood.
Drains: None.
Specimens: No samples of wound.
Complications: None.
Condition of patient: Patient tolerated procedure well without significant blood loss and was
stable upon discharge from the ED.
Follow up:
1. Vaccination: TDAP
a. 5 cc TDAP vaccination injected into left deltoid while in ED.
b. Side effects of TDAP including: pain, redness or swelling at injection site, mild
fever of at least 100.4 F, nausea, vomiting, chills, body aches, headache.
c. Patient educated on importance of tetanus prophylaxis and to obtain TDAP
vaccination every 10 years.
2. Wound care
a. Patient instructed to clean wound area daily with soap and water. OTC Bacitracin
or Neosporine may be used if wound appears dry.
b. Keep wound covered with 4x4 gauze and tape to prevent skin irritation and
infection.
c. Leave sutures in for 10 days, do not remove before that time.
3. Follow up
a. Patient advised to follow up with Dr. Kreider, FMD, for wound check in 5 days to
ensure no secondary infection and suture removal in 10 days.
b. Patient advised to return to ED if wound reopens, bleeding recurs, signs of
infection including redness, tenderness, swelling, warmth or discharge from
wound site.
Alyson Wattai, PA-S