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Assessment:
Patient presents with a localized reaction to an insect bite, characterized by redness, swelling, and mild itching at the site. No signs of secondary infection or systemic symptoms are noted. Differential diagnoses include allergic reaction, contact dermatitis, and other skin infections.
Plan:
Recommend conservative management with cool compresses to reduce swelling and itching. Advise the use of over-the-counter antihistamines (e.g., diphenhydramine) for itching and oral analgesics (e.g., ibuprofen) for discomfort. Educate the patient on monitoring for signs of infection, such as increased redness, warmth, or discharge. Schedule a follow-up if symptoms worsen or do not improve in a few days. Document response to treatment at the next visit.
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