What assessment and management plan is indicated for a 25‑year‑old male who presents after a self‑inflicted stab wound to the left forearm with a contaminated fork, has cyclothymic disorder and attention‑deficit/hyperactivity disorder treated with aripiprazole 10 mg daily and lamotrigine 100 mg daily, unknown tetanus immunization status, and is otherwise hemodynamically stable with a normal physical exam?

Assessment and Management Plan

Immediate Wound Management

The patient requires thorough wound irrigation, debridement if indicated, and prophylactic antibiotics for a contaminated puncture wound to the forearm. 1

Wound Care Protocol

• Cleanse the wound with sterile normal saline (no need for iodine- or antibiotic-containing solutions) and remove superficial debris 1
• Deeper debridement should be performed cautiously to avoid enlarging the wound and impairing skin closure 1
• Do not suture the wound primarily—infected or contaminated wounds should not be closed 1
• Approximate wound margins with Steri-Strips and plan for delayed primary or secondary closure 1
• Elevate the injured forearm using a sling to accelerate healing, especially if swelling is present 1

Antibiotic Prophylaxis

Initiate prophylactic antibiotics immediately given the contaminated nature of the fork (freshly used, unclean). 1

• First-line regimen: Amoxicillin-clavulanate (Augmentin) to cover oral flora including β-lactamase-producing anaerobes 1
• Alternative options include second-generation cephalosporins (cefoxitin) or fluoroquinolones with anaerobic coverage 1
• Duration: 3–5 days for prophylaxis; extend to 4 weeks if septic arthritis develops or 6 weeks if osteomyelitis is confirmed 1
• The bacteriology of self-inflicted fork wounds mirrors human bite wounds, with streptococci (80%), staphylococci, and anaerobes (60%) including Fusobacterium and Prevotella species 1

Monitoring for Complications

• Pain disproportionate to injury severity suggests periosteal penetration—obtain radiographs if bone or joint involvement is suspected 1
• Infectious complications include septic arthritis, osteomyelitis, subcutaneous abscess, and tendonitis 1
• Schedule follow-up within 24 hours (phone or office visit) to assess for progression of infection 1

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Tetanus Prophylaxis

Administer tetanus toxoid (Td or Tdap) 0.5 mL intramuscularly immediately because the patient's tetanus immunization status is unknown (documented as "[DATE]" without specifics). 1, 2

• Tetanus immune globulin (TIG) is NOT indicated for this patient because the wound is a minor, clean puncture (not a deep, contaminated wound with devitalized tissue) and TIG is reserved for high-risk wounds in patients with uncertain or incomplete vaccination history 1, 2
• If the patient has never received a primary tetanus series or the last dose was >10 years ago, complete the primary series with additional doses at 4 weeks and 6–12 months 1
• Administer the injection in the deltoid muscle, not the gluteal region, to avoid sciatic nerve injury 2

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Psychiatric Assessment and Safety Planning

This patient requires immediate psychiatric evaluation for suicide risk given the self-harm behavior in the context of cyclothymic disorder. 3

Suicide Risk Stratification

• Conduct a comprehensive suicide risk evaluation assessing self-directed behaviors, current suicidal thoughts, psychiatric conditions, social determinants, access to lethal means, and additional risk factors (male gender, impulsivity, anger) 3
• High-risk criteria requiring psychiatric hospitalization include: persistence in endorsing desire to die, continued agitation or severe hopelessness, inability to participate in safety planning, inadequate support system, or history of high-lethality attempts 3
• Interview the patient and collateral sources (family, [RELATIVE]) separately to obtain accurate history 3
• Place the patient in hospital attire after searching personal belongings to remove access to potential means of self-harm, and assign continuous observation 3

Disposition Decision

• If the patient meets high-risk criteria, arrange immediate psychiatric hospitalization 3
• If the patient is deemed low-risk for imminent self-harm, develop a comprehensive safety plan before discharge that includes: identification of warning signs and triggers, concrete coping strategies, list of responsible social supports, professional support contacts, and clear instructions on accessing emergency services 3
• Counsel on lethal means restriction: secure all medications, remove firearms from the home, and eliminate access to other potential means of self-harm 3

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Medication Management Considerations

Current Psychiatric Regimen Review

The patient is maintained on aripiprazole 10 mg daily and lamotrigine 100 mg daily for cyclothymic disorder and ADHD. 1, 4

• Continue current medications unless psychiatric evaluation indicates need for adjustment 1
• Aripiprazole is FDA-approved for bipolar disorder and has evidence for mood stabilization 4
• Lamotrigine is effective for bipolar depression and mood stabilization 1
• Avoid prescribing benzodiazepines or phenobarbital in this suicidal patient, as these medications reduce self-control 3
• If antidepressant therapy is indicated, use SSRIs (fluoxetine, sertraline) due to their low lethality in overdose 3

Cyclothymic Disorder and ADHD Comorbidity

• Cyclothymic temperament is highly prevalent in adults with ADHD (71% vs. 13% in controls) and characterizes a subgroup with greater psychiatric impairment, possibly reflecting underlying affective instability closer to the bipolar spectrum 5
• Emotional dysregulation is central to the overlap between ADHD and cyclothymia, with both conditions showing similar levels of emotional dysregulation 6
• Patients with both conditions show significantly higher affective instability and negative emotional dysregulation 6

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Follow-Up and Monitoring

Wound Follow-Up

• Recheck the wound within 24 hours to assess for signs of infection (erythema, warmth, purulent drainage, fever) 1
• If infection progresses despite antibiotics and wound care, hospitalize the patient for intravenous antibiotics 1

Psychiatric Follow-Up

• Arrange outpatient psychiatric follow-up within 1 week if discharged from the emergency department 3
• Ensure the patient has access to crisis resources including 24-hour crisis hotline numbers and instructions to return to the emergency department if suicidal thoughts worsen 3
• Coordinate care with the patient's outpatient psychiatrist to review medication regimen and assess need for intensification of treatment 1

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Common Pitfalls to Avoid

• Do not underestimate the seriousness of self-harm with a fork as a suicide gesture—full psychiatric evaluation is required regardless of the low medical severity of the wound 3
• Do not rely exclusively on screening tools to determine suicide risk—use multiple assessment methods including clinical interview and collateral information 3
• Do not delay antibiotic prophylaxis—contaminated puncture wounds require immediate coverage for oral flora 1
• Do not assume tetanus immunization is current when documentation is incomplete—administer tetanus toxoid when status is unknown 1, 2
• Do not discharge the patient without a comprehensive safety plan and lethal means counseling 3