Reporte zur Charge P7N2HPP

Symptomtext

9/17/21 9:29 AM: 56 yof c/o nausea, diarrhea, HA, fatigue, dizziness, L arm at inj site pain/redness/swelling/warmth x 2d Pt in no resp distress Pt speaking in clear and complete sentences Pt A&O x 4 Pt reports that she had chills the first day Started with the arm SXs 24h later; redness 1 in around inj site Pt reports inj site has gotten worse; 4 in bright red around inj site, bumpy, hot, hard, painful, itchy, swelling around site Current pain level: 6/10 L arm; 3/10 HA Last took Advil 2d ago; with relief Denies difficulty breathing, difficulty speaking, sudden swelling in back of throat Denies CP, fainting, palpitations, confusion, agitation, dec LOC Denies fever, chills, drainage Pt scheduled with nurse at 3:20 PM 9/17/2021 3:20 PM nurse visit: 56 yof c/o nausea, diarrhea, HA, fatigue, dizziness, L arm at inj site pain/redness/swelling/warmth x 2d Has been taking Advil with relief; last taken 2d ago Pt in no resp distress Pt speaking in clear and complete sentences Pt A&O x 4 Currently Dull HA; sides of head/frontal; 2/10 Mild dizziness; denies vision changes, room spinning, feeling faint; lasts less than 1 min; aggravating: denies; alleviating: denies L inj site: Currently burning, itching, stinging, painful 2/10 3.5 x 2 in site Notes some improvement from yest Redness, swelling, warmth, firmness, pain on palpitation Meds: Denies Allergies: Denies Consulted with provider NP whom saw pt: Benadryl 50 mg at home; 25 PO during the day Can also use topical Benadryl Pepcid Cold compresses Arm should heal in 3-4d with using consistently OK to receive Shingles #2 that is scheduled for 10/2021 Pt states that she has above at home Home care instructions and ER precautions provided Instructed pt to advise if SXs worsen or new SXs arise Pt verbalized understanding and had no further questions Pt left clinic in stable and ambulatory condition