Laceration without foreign body of unspecified part of neck initial encounter Intentional self-harm by knife initial encounter Major depressive disorder single episode unspecified
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
self-inflicted wound
 
Major Surgical or Invasive Procedure:
___: Bedside neck laceration repair with sutures and 
___ drain placement. 
 
History of Present Illness:
Mr. ___ is a ___ yo gentleman with two prior suicide attempts 
___ and ___ and one prior psychiatric hospitalization (___) 
with previous diagnosis of depression (s/p 6 Ketamine treatments 
in ___ for "refractory depression") who called an ambulance 
after stabbing self in the neck in hopes of ending his life.
 
Past Medical History:
unspecified depressive disorder

 
Social History:
___
Family History:
- ___ Dx: father has "socialization" issues, mother has
depression
 - ___ Hospitalizations: denies
 - ___ Treatment Hx/Med Trials: mother on antidepressant
 - ___ Hx Suicide: uncle with suicide 

 
Physical Exam:
Admission Physical Exam:

GA: Comfortable Neuro: GCS of 15, moves all 4 extremities HEENT: 
No
scleral icterus, no hemotympanum, no maxillary mandibular 
instability, zone
two 5 to 7 cm irregular laceration with violation of the areolar 
tissue noted to be
oozing blood but not pulsatile Cardiovascular: Normal S1, S2, 
regular rate and
rhythm, no murmurs/rubs/gallops, 2+ peripheral pulses 
bilaterally Pulmonary:
Clear to auscultation bilaterally Abdominal: Soft, nontender, 
nondistended, no
masses Extremities: No lower leg edema Integumentary: Old 
laceration to times
on left forearm anterior aspect

Discharge Physical Exam:
VS: T98.4, BP 142 / 81, HR 93, RR 18, O2 99 Ra      
GEN: NAD, flat affect, slow response to questions
HEENT: right neck wound about 6 inches wide, sutures with 
non-absorbable material. well approximated without erythema, 
drainage, or fluctuance. Non-tender
CV: RRR, no m/r/g
PULM: CTAB, no w/r/g
ABD: soft, NT, ND
EXT: WWP, no edema, 2+ periperhal pulses
 
Pertinent Results:
IMAGING:

___: CTA Neck:

1. Large skin laceration along the right anterior triangle (zone 
2) with 
subcutaneous air extending beyond the plane distance muscle into 
the right 
parapharyngeal space abutting the right common facial vein. 
2. No evidence of pseudoaneurysm or caliber narrowing involving 
the right 
common carotid, internal carotid and major branches of the right 
external 
carotid artery to suggest injury at this time.  No active 
contrast 
extravasation or large hematoma. 
3. No findings to suggest arteriovenous fistula at this time. 
4. Visualized aerodigestive track is grossly unremarkable.  No 
evidence of 
emphysema in the retropharyngeal or pre vertebral soft tissues 
to suggest 
esophageal perforation. 
5. Additional findings described above. 

___: CXR:
No acute cardiopulmonary abnormality.  No displaced fracture.

___:  BARIUM SWALLOW/ESOPHAGU:
No evidence of leak. 
  

___ 11:00AM BLOOD WBC-6.8 RBC-5.47 Hgb-15.3 Hct-44.9 MCV-82 
MCH-28.0 MCHC-34.1 RDW-12.0 RDWSD-35.8 Plt ___
___ 06:41PM BLOOD ___ PTT-25.2 ___
___ 11:00AM BLOOD Glucose-109* UreaN-11 Creat-1.0 Na-141 
K-4.3 Cl-101 HCO3-26 AnGap-14
___ 11:00AM BLOOD Calcium-10.3 Phos-3.1 Mg-2.0
___ 06:41PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG 
Tricycl-NEG
___ 06:41PM BLOOD Lipase-___ y/o M who presented to ___ s/p self-inflicted stab wound to 
zone 2 of the neck.  He had a CTA which was negative for deeper 
blood vessel injury.  He had a barium swallow which was negative 
for leak.  His neck wound was repaired with sutures and a 
___ drain was placed.  The patient was admitted to the Acute 
Care Surgery/Trauma service for further care.

After remaining hemodynamically stable, the patient was 
transferred to the surgical floor.  He was started on a regular 
diet which he tolerated well. Psychiatry was consulted.  He was 
placed in 1:1 seclusion for safety.  The patient was calm and 
oriented throughout hospitalization.

On ___, the ___ drain was removed and the patient was 
screened for inpatient psychiatry.  His incision remained well 
approximated with sutures with minimal serous output

At the time of transfer, the patient was doing well, afebrile 
and hemodynamically stable.  The patient was tolerating a diet, 
ambulating, voiding without assistance, and pain was well 
controlled.  The patient received discharge teaching and 
follow-up instructions with understanding verbalized and 
agreement with the discharge plan.
 
Medications on Admission:
None
 
Discharge Medications:
1.  Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever  

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
Self-inflicted stab wound to zone 2 ___ischarge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
 
Discharge Instructions:
Dear Mr. ___,

You were admitted to the hospital with a stab wound to your 
neck.  The wound was repaired with sutures and a ___ drain 
was left in place to allow for drainage and to prevent 
infection.  The drain was later removed and your wound is 
healing well.  You had imaging done which did not show damage to 
the major blood vessels of the neck or injury to the throat.  

You are now ready to be discharged to inpatient psychiatry.  
Please note the following discharge instructions:

YOUR INCISION: -Your incisions may be slightly red. This is 
normal. -You may gently wash away dried material around your 
incision. -Avoid direct sun exposure to the incision area. -Do 
not use any ointments on the incision unless you were told 
otherwise. -You may see a small amount of clear or light red 
fluid staining your dressing or clothes. You can put a piece of 
gauze over this to cover the area -You may shower. You should 
not take baths or swim

If you have any questions or concerns, please call the ___ 
clinic at ___.
 
Followup Instructions:
___

{'self-inflicted wound': ['Intentional self-harm by knife', 'Laceration without foreign body of unspecified part of neck'], 'depression': ['Major depressive disorder']}