Note: Sample only, done by a second-year visiting medical student from the USA in 1999. Just to illustrate the patient management processes.

KKJ

Patient Management Process

Surgical Case Presentation

CASE PRESENTATION:

General Data: MD is a 44 year-old female.

CC: Pain due to abscess in the right axilla.

HPI: Abscess initially presented one month ago, but subsided on its own. Current abscess returned two weeks ago and is larger than the original abscess.

PE: Abscess is located in the center of the right axilla and is approximately 3-4 cm in diameter and 1 cm raised. Abscess is red and has clearly defined borders. It is tender and painful upon palpation and appears inflamed. Fluctuance is noted, and the abscess appears to be fluid-filled. Diagram:

CASE DISCUSSION:

Clinical Diagnosis:

1) The data from the database which can serve as cues for a clinical diagnosis in this case come mainly from the PE (Signs).

2) Primary Clinical Diagnosis: Abscess

Secondary Clinical Diagnosis: Cellulitis

3) Based on the signs found in the PE and by using pattern recognition, I concluded that the problem could be either an abscess or cellulitis. The reason that I made abscess my primary diagnosis over cellulitis is the presence of fluctuance. In other words, abscesses are fluid-filled whereas cellulitis does not present with any fluid. Consequently, I am over 90% certain of my primary diagnosis. Given that I am very certain that the problem in this case is an abscess, that could be further classified depending on the origin of the abscess. Thus, the abscess could be due to either an inflamed hair follicle or an obstructed sebaceous gland. There is no way to determine this strictly based on PE, so based on prevalence and the location of the abscess, I would change my primary and secondary clinical diagnoses to the following:

Primary Clinical Diagnosis: Abscess due to inflamed hair follicle

Secondary Clinical Diagnosis: Abscess due to obstructed sebaceous gland

Paraclinical Diagnostic Procedures:

1) Primary Clinical Diagnosis: Abscess due to inflamed hair follicle

Secondary Clinical Diagnosis: Abscess due to obstructed sebaceous gland

2) Certainty Treatment Modality

Abscess (Hair follicle) 60% Incision and drainage

Abscess (Sebaceous gland) 40% Incision and drainage

Although the certainty of the primary diagnosis is not significant in this case, it is not important because the treatment modalities for both diagnoses are identical. (Also, both diagnoses are abscesses and the importance of the source of the abscess is minimal when trying to determine whether or not a paraclinical diagnostic procedure is necessary.) Consequently, I conclude that a paraclinical diagnostic procedure is NOT NECESSARY in this case.

Treatment:

1) Primary Pretreatment Diagnosis: Abscess due to inflamed hair follicle

Secondary Pretreatment Diagnosis: Abscess due to obstructed sebaceous gland

2) The goals of treatment for the primary diagnosis are relief of the pain and associated discomfort, treatment of the inflammation, and satisfaction of the patient.

3) Treatment Modality:

Based on this data, I conclude that the best treatment in this case would be an incision and drainage of the abscess. This is mainly because the risks associated with this procedure are acceptable as well as the cost. It will also provide faster relief than antibiotics. More importantly, the antibiotics may not be effective and the abscess could then worsen. Thus, I would obtain informed consent from the patient to go ahead with the incision and drainage of the abscess.

4) The outcome of the proposed treatment will be evaluated depending on how successful it is in achieving the goals of treatment stated above in relation to any negative effects that may have occurred during the procedure.

5) An incision and drainage was performed on the patient, but no follow-up data is available at this time.

Prevention and Health Promotion:

1) The final diagnosis is an abscess, and the source of the abscess would have been determined intra-operatively. If the pus contained within the abscess appeared yellow and oily, then the conclusion would have been that the abscess was caused by an obstructed sebaceous gland. If the pus did not appear oily, then the conclusion would have been that the abscess was caused by an inflamed hair follicle.

2) I would advise the patient that the abscess was caused by either an inflamed hair follicle or an obstructed sebaceous gland (depending on what the intra-operative findings were). I would then draw the following diagram for the patient to aid in my explanation of the problem:

Finally, I would explain that the patient could prevent this kind of problem in the future by using better hygiene practices while shaving the axilla. For example, she should always use clean equipment such as blades or tweezers. She should also wash in that area with soap and water both before and after grooming. (I would present this information in a sensitive manner in order to avoid offending the patient.)

ROJ@11dec18