Subjective This patient is a 64 year old white female with a

Last updated: 1/26/2023

Subjective This patient is a 64 year old white female with a significant past medical history of being admitted to the hospital this last week due to a bowel obstruction She states where she had an IV in her left antecubital area and now she has some redness and swelling up into the bicep region of her arm She was concerned about a possible infection She has had no drainage discharge or bleeding from the site She has no fever or chills No nausea or vomiting Objective In general the patient was alert oriented and appropriate She did not appear to be either toxic or dehydrated Examination of the left antecubital area did reveal a puncture site There is appears to be some erythema extending up into the bicep region of the arm distally There is no evidence of discrete abscess formation It was not tender to palpation but was slightly warm There is no drainage or discharge No evidence of discrete abscess formation No distal edema or evidence of DVT Assessment Acute thrombophlebitis left arm Plan At this time the patient was instructed to use anti inflammatories needed for pain or inflammation Warm compresses Recheck with her primary care physician she already has an appointment to follow up on Tuesday