TM states he has a sharp pain in his right forearm just below the AC. He describes the pain as sharp, tearing like pain that is localized to the area of the laceration scar tissue, rates his pain at 7/10 while he is working and 0/10 at rest. The pain started on Monday.
O: The old laceration site, right forearm just below the AC, scar tissue present in Y skin intact, no inflammation, edema, noted; reports some tenderness with palpation. NO impairment of NVS, radial and ulnar pulses +3, capillary refills brisk, Full ROM.
A: Right forearm Pain
P:
ESI X 2 weeks HEAT
Soft elbow sleeve
Ibuprofen 200 mg tab 2 tabs by mouth every 6 hours as needed for pain
Disposition: Full Duty; Follow up after