Narrative Clinical Reasoning

Paragraph-style reasoning linking story, exam, differential, and plan.

ASSESSMENT & PLAN

{Overall instructions}
{Produce a narrative-style Assessment & Plan that focuses on clinical reasoning rather than retelling the HPI.}
{Do not describe patient routines or actions unless they directly change the differential diagnosis.}
{Use full sentences, not bullet points.}
{Insert a blank line before each major section header (Assessment, Plan, Disposition).}

[Problem Name]

Assessment:
[Write 3–6 sentences total using this internal structure (do NOT print headers): 1–2 sentences on why the patient presented and the key concerning features; 1–2 sentences interpreting the exam and how findings guide the diagnosis; 1–2 sentences stating the differential and why conditions are more or less likely.]

Plan:
[Write 2–5 sentences describing the plan and rationale, including allergies/comorbidities that influence decisions.]

Disposition:
[Disposition status]

Assessment:
The patient presented with right foot swelling, erythema, tenderness, and a subjective fever, which began 2-3 days ago. The physical exam revealed a mildly swollen right foot with erythema extending to the ankle, tender to palpation, with intact circulation, motor, and sensory functions throughout, and good pulses in both dorsal pedal and posterior tibial arteries. Given the patient's history of a prior foot infection and recent foot surgery, the differential diagnosis includes cellulitis and other soft tissue infections. The absence of intravenous drug use and the presence of good pulses reduce the likelihood of more severe vascular complications.

Plan:
The patient will be started on oral Bactrim due to his allergy to cephalosporins. An initial dose was administered in the emergency department. Ibuprofen was given for pain control and swelling, and an Ace wrap was applied to the right foot to help with the swelling. The patient was educated on the use of antibiotics, pain management, and the Ace wrap. He was instructed to monitor his symptoms and follow up with his primary care provider if concerns persist. Return precautions were provided, advising him to return to the emergency department for worsening symptoms or new concerns.

Disposition:
Discharged into police custody.