URGENT CARE
SUBJECTIVE: This 25-year-old male presents with a small laceration to his right distal thigh. He notes he was in a store this evening, when he moved to avoid some people in the aisle, and struck his leg against a metal shelf resulting in this laceration. The patient is not current on his tetanus immunization. He originally was not going to come in for sutures, but the laceration is near his knee and he has to work on his knees a lot as an auto body repairman.
OBJECTIVE: Physical exam reveals a well-developed, well-nourished male. He is alert and oriented and in no acute distress. Vital signs are within normal limits. Exam of his right distal thigh reveals a 2.5 cm linear laceration through the dermis just proximal to the knee. The wound was cleaned, irrigated with normal saline, injected with 1% Xylocaine with epinephrine. It was then sutured with 4-0 interrupted nylon sutures. Neosporin ointment and a dressing were placed over the wound. The patient was also given a DT booster.
ASSESSMENT: Laceration, right distal thigh, sutured.
PLAN: Wound care instructions include suture removal in 10 - 14 days. He is to watch closely for any signs of infection and return to the emergency room should this occur.
ICD-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
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