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Puncture Wound Follow Up: A Case Study

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Reason for Visit: Puncture Wound Follow Up
S: TM started on Cipro 500 mg BID yesterday for his left arm puncture wound yesterday. TM reports the redness and edema has improved and minimal pain with palpation to his left FA; 2/10. TM denies any issues at this time to his left FA. TM reports tenderness to his tetanus IM injection site; right shoulder.
O: minimal redness to left FA puncture wound; harden area, radius of 2 cm; no warmth palpated; no s/s of infection noted, Left arm NVS intact, no impairment of movement in Left arm. Right shoulder IM injection site, no redness or edema, tenderness to palpation, no impairment of right arm movement, or NVS, brisk capillary refills
A: Left Forearm Puncture Wound
P: Complete antibiotic as ordered Follow

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