thescientist8
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pt referred to the office yesterday for a possible mass of left posterior forearm. Pt states it has been present for approx 2 weeks. His daughter states it has been decreasing in size. no complaints from patient.
pt had sono performed which showed a fluid colelction measuring approx 8.3x1.6x4.4cm of the left dorsal forearm. pt w/ no complaints; he does not recall specific trauma to the site;but he states it may have occured.
PMHx: HTN, pacemaker,gout
on Exam:
There is a raised fluctuance of left posterior forearm
no cellulitis;no sign of infection;non tender
consent was obtained
area prepped with alcohol;18 ga needle inserted several times into collection
approx 10 cc fluid drained; appeared serosang, fluid was sent for culture
not turbid
Assesment/Plan
Appears that the pt may have sustained hematoma/seroma from possible trauma. there is still possible some fluid which remains-which will likely resorb
pt had sono performed which showed a fluid colelction measuring approx 8.3x1.6x4.4cm of the left dorsal forearm. pt w/ no complaints; he does not recall specific trauma to the site;but he states it may have occured.
PMHx: HTN, pacemaker,gout
on Exam:
There is a raised fluctuance of left posterior forearm
no cellulitis;no sign of infection;non tender
consent was obtained
area prepped with alcohol;18 ga needle inserted several times into collection
approx 10 cc fluid drained; appeared serosang, fluid was sent for culture
not turbid
Assesment/Plan
Appears that the pt may have sustained hematoma/seroma from possible trauma. there is still possible some fluid which remains-which will likely resorb