Patient presents with localized soft tissue swelling, possibly indicative of edema, inflammation, or soft tissue injury.  Onset of swelling was (onset date or duration) and is located in the (anatomical location).  Patient describes the swelling as (character of swelling: e.g., painful, non-painful, tender, warm, erythematous, fluctuant, indurated).  The size of the swelling is approximately (measurement) and (shape).  Mechanism of injury, if applicable, is described as (mechanism of injury).  Patient reports (associated symptoms: e.g., pain, limited range of motion, redness, warmth, numbness, tingling).  Medical history significant for (relevant medical history, e.g., trauma, surgery, infection, inflammatory conditions, medications).  Physical examination reveals (objective findings: e.g., palpable mass, tenderness to palpation, increased skin temperature, erythema, ecchymosis, crepitus, restricted range of motion).  Differential diagnosis includes soft tissue contusion, hematoma, muscle strain, sprain, cellulitis, abscess, bursitis, tendonitis, tenosynovitis, lymphedema, and deep vein thrombosis.  Ordered (diagnostic tests, e.g., ultrasound, MRI, X-ray) to further evaluate the swelling and rule out other potential causes.  Initial treatment plan includes (treatment plan: e.g., RICE therapy rest, ice, compression, elevation, NSAIDs, analgesics, antibiotics, immobilization).  Patient education provided regarding (patient education topics: e.g., activity modification, pain management, signs and symptoms of infection, follow-up care).  Follow-up scheduled for (follow-up date) to reassess swelling and adjust treatment plan as needed.  ICD-10 codes considered include (potential ICD-10 codes, e.g.,  M79.89, R22.2, T14.0xxA, depending on etiology) and CPT codes for procedures performed will be documented separately.