Clinical Documentation for Healed Blister Following Cellulitis
The patient has completed successful treatment of left 4th digit cellulitis with complete resolution—no further antibiotic therapy or intervention is indicated at this time. 1
Improved Documentation
Chief Complaint: Follow-up evaluation of left 4th digit cellulitis
History of Present Illness: Patient presents for follow-up of previously diagnosed left 4th digit cellulitis. The blister that formed during the acute infection has spontaneously deroofed, with the overlying skin having separated and fallen off. The patient reports complete resolution of symptoms including:
- No pain or tenderness
- No fever or chills
- No systemic symptoms
Physical Examination:
- Left 4th digit: Healed blister site with no residual open wound or erosion
- No erythema or induration extending beyond the original site
- No edema or swelling
- No purulent drainage or exudate
- No warmth to palpation
- No lymphangitic streaking
- No regional lymphadenopathy
Assessment: Resolved left 4th digit cellulitis with healed blister, no evidence of active infection or complications
Plan:
- No further antibiotic therapy required given complete clinical resolution 1
- Routine wound care with plain petrolatum ointment if any minor skin irritation present 1
- Patient educated on signs of recurrent infection requiring immediate evaluation: new erythema, warmth, swelling, pain, purulent drainage, or fever 1
- Address predisposing factors: examine interdigital spaces for tinea pedis or fissuring; maintain good skin hygiene 1
- No follow-up appointment needed unless symptoms recur 1
Key Clinical Points
Why No Further Treatment Is Needed:
- Complete absence of erythema, induration, warmth, and tenderness indicates resolved infection 1, 2
- Healed blister without open erosion or wound requires only observation 1
- Standard cellulitis treatment duration is 5-10 days with extension only if symptoms persist—this patient has achieved complete resolution 1
Prevention of Recurrence: