Chapter 10: The Cardiovascular System | Carrie Geiger's Chart Note

CHART NOTE

Patient Name: Geiger, Carrie
ID Number: 67854
Examination Date: April 4, 20xx

SUBJECTIVE
Carrie is a 24-year-old female who presents with swelling, redness, and tenderness of the right posterior extremity, present for the past 72 hours and becoming more uncomfortable and swollen. She has some pain with walking. It is worse after being on her feet all day. She recalls no direct trauma to the area. She is on birth control pills. Nonsmoker.

OBJECTIVE
She has localized erythema, induration (areas of hardened tissue), tenderness, and edema along the right lower extremity. Varicose veins noted distally and proximally.

ASSESSMENT
Chronic venous insufficiency with superficial thrombophlebitis. No deep vein venous thrombosis.

PLAN
Ibuprofen 60 mg BID with food (take a 60-mg tablet of ibuprofen twice a day). Apply warm compresses to the affected area for 30–60 minutes TID (three times a day). Elevate leg as needed. Will recheck in 2–3 weeks or sooner if no improvement.