Moderate MDM / Documentation-Dense

Coder-friendly MDM with differential, data review, risk, plan.

ASSESSMENT & PLAN

{Overall instructions}
{Produce a structured, moderate-intensity Medical Decision Making style Assessment & Plan.}
{Include clinical reasoning, differential diagnosis, data review, risk elements, and rationale.}
{Use concise paragraphs; bullets only where specified.}
{Insert a blank line before each section header.}

[Problem Name]

Assessment:
[3–5 sentence summary of presentation, key findings, interpretation, and reasoning supporting the working diagnosis.]

Differential Diagnosis:
- [Most likely diagnosis + 1 sentence rationale.]
- [Possible alternative diagnosis + rationale.]
- [Less likely diagnosis considered + rationale.]

Data Review:
- [Tests ordered or reviewed + relevance.]
- [External records reviewed + relevance.]
- [Consultant input + brief summary.]

Risk Assessment:
[1–3 sentences describing risk drivers (e.g., comorbidities, Rx drug management, hospitalization decision).]

Plan:
[2–5 sentences describing interventions performed, medications given, responses, and rationale; why testing was or was not pursued.]

Disposition:
[Disposition status]
[1–2 sentences on rationale for disposition]

Right Foot Swelling

Assessment:
The patient presents with right foot swelling, erythema, tenderness, and a subjective fever, which began 2-3 days ago. The physical exam reveals a mildly swollen right foot with erythema extending to the ankle, tender to palpation, but with intact circulation, motor, and sensory functions. The patient's history of prior foot infection and recent abrasion from scratching due to itchiness supports the likelihood of a soft tissue infection, such as cellulitis.

Differential Diagnosis:
- Cellulitis: The presence of erythema, swelling, tenderness, and fever are consistent with cellulitis, a common soft tissue infection.
- Abscess: Although less likely, the persistent swelling and tenderness could indicate an underlying abscess, which may not be immediately apparent without further imaging.
- Deep Vein Thrombosis (DVT): Considered less likely due to the absence of risk factors such as immobility, recent surgery, or intravenous drug use, and the presence of good pulses.

Data Review:
- No tests ordered or reviewed.
- External records reviewed indicate a prior foot infection treated in 2024, which is likely unrelated to the current presentation.
- No consultant input was sought.

Risk Assessment:
The patient's cephalosporin allergy necessitates careful selection of antibiotics. The presence of a prior foot infection and recent abrasion increases the risk of recurrent or complicated infection. The patient's subjective fever and erythema extending to the ankle suggest a moderate risk of progression if not promptly treated.

Plan:
The patient was administered oral Bactrim due to his cephalosporin allergy, which is effective against common pathogens causing cellulitis. Ibuprofen was given for pain control and to reduce swelling. An Ace wrap was applied to the right foot to help manage the swelling. No additional testing was pursued as the clinical presentation was sufficiently clear to warrant immediate antibiotic therapy.

Disposition:
Discharged into police custody. The decision to discharge was based on the patient's stable condition, intact circulation, motor, and sensory functions, and the initiation of appropriate antibiotic therapy. Follow-up with a primary care provider was advised if concerns persist, and the patient was instructed to return to the emergency department for worsening symptoms or new concerns. Patient education was provided on antibiotics, pain management, and Ace wrap use.