CHIEF COMPLAINT: Left arm redness.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who presented with a chief complaint of left arm redness. The patient reports that she was admitted to the hospital and discharged yesterday. The patient reports since that time she has noted some redness to her left antecubital fossa where she had an IV.
The patient reports no pain to the area and no warmth. She notes that she is concerned secondary to redness, which has not enlarged at all since noticing the area. She has taken nothing for the pain prior to arrival here. She reports she has otherwise been well.
PAST MEDICAL HISTORY: Negative.
PAST SURGICAL HISTORY: Negative.
MEDICATIONS AND ALLERGIES: See chart.
SOCIAL HISTORY: The patient smokes one pack of cigarettes per day. The patient denies any alcohol or illicit drug use. The patient currently lives at home with others.
FAMILY HISTORY: Negative for heart disease, diabetes or cancer.
REVIEW OF SYSTEMS: Please see history of present illness. All other systems are reviewed and negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse oximetry 98% on room air, temperature 37.2 orally, respirations 18, pulse 106 and regular, and blood pressure 140/76.
GENERAL APPEARANCE: The patient is a well-developed female who was seen sitting in bed, appears comfortable, in no acute distress, and nontoxic in overall appearance.
HEENT: Normocephalic.
HEART: Regular rate and rhythm. There are no murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally without wheezes, rales or rhonchi.
ABDOMEN: Soft, nontender, and nondistended.
EXTREMITIES: Distal pulses are 2/4 in bilateral upper and lower extremities. Sensation appears intact throughout. Strength is 5/5 in bilateral upper and lower extremities. The patient demonstrates erythema in the left antecubital fossa consistent with possible superficial thrombophlebitis.
PSYCHIATRIC: The patient is alert and oriented x3, is pleasant and conversational, and has normal affect.
SKIN: Appears warm, dry, and intact. No evidence of any lacerations or abrasions. The patient demonstrates ecchymosis in her bilateral antecubital fossa consistent with a history of IV placed, and she does demonstrate slight erythema, approximately 2 cm in diameter, in the left antecubital fossa. No warmth noted to the area. No streaking or fluctuance noted. No drainage noted from this region.
DIAGNOSTIC STUDIES: None.
EMERGENCY DEPARTMENT COURSE: The patient was seen and examined. History and physical was completed above. Studies were not done at this time. Ultimately, the patient presents with erythema consistent with superficial thrombophlebitis. She had the area outlined with a surgical marking pen and was instructed regarding washing the area, to continue warm compresses at home. Ultimately, the patient was given prescriptions for Bactrim and Keflex to start if the area should increase in redness outside of the area of margins, and she needs to follow up with Dr. John Doe in approximately four to five days. She understood all plans for discharge and has no further questions at this time.
FINAL DIAGNOSIS: Superficial thrombophlebitis.
PLAN: The patient will be discharged to home in improved and stable condition and has been instructed to follow up with her primary care within the next four to five days.
CONDITION AT DISCHARGE: Stable.
