Date:
Patient:
Reason for Visit:
Evaluation of suspected skin abscess
Follow-up for existing skin abscess
History:
Presenting Illness:
Location, size, and duration of the abscess
Color, warmth, and tenderness of the overlying skin
Drainage of pus (present/absent)
Fever, chills, or other systemic symptoms (present/absent)
Recent skin trauma, insect bites, or furuncles (boils)
Past Medical History (PMH):
Underlying medical conditions (e.g., diabetes, chronic skin conditions) that may increase risk of infection
History of recurrent skin abscesses
Allergies to medications (especially antibiotics)
Physical Exam:
General: Assess for vital signs (temperature, heart rate, blood pressure) and signs of systemic infection (fever, malaise).
Skin: Examine the abscess for location, size, erythema (redness), induration (hardness), warmth, and fluctuance (fluid collection).
Lymph Nodes: Palpate regional lymph nodes for enlargement or tenderness.
Diagnostic Tests:
Aspiration (may be performed): Using a sterile needle and syringe, pus is withdrawn from the abscess for analysis and culture to identify the causative organism.
Blood cultures (may be ordered if systemic symptoms are present): To rule out bloodstream infection.
Assessment:
Diagnosis: Confirm skin abscess based on clinical presentation and aspiration findings (if performed).
Severity of infection: Evaluate based on size, surrounding inflammation, and presence of systemic symptoms.
Possible causative organism: Consider based on clinical presentation and culture results (if available).
Plan:
Treatment:
Antibiotics: Initiate oral antibiotics based on empiric coverage for common skin abscess pathogens (e.g., staphylococcus aureus). Narrow spectrum therapy may be considered based on culture results.
Warm compresses: Apply warm compresses to the area several times a day to promote drainage.
Pain management: Over-the-counter pain medication (e.g., ibuprofen, acetaminophen) for discomfort.
Incision and drainage (I&D): Consider I&D by a healthcare professional for large or fluctuant abscesses not responding to antibiotics alone.
Follow-up:
Schedule a follow-up visit within 24-48 hours to assess response to treatment.
Re-evaluate the abscess for signs of improvement (decreased swelling, redness).
Adjust antibiotic therapy based on culture results, if available.
Consider repeat aspiration if necessary.
Patient education:
Instruct on proper wound care (cleaning, applying warm compresses).
Emphasize the importance of completing the entire course of antibiotics.
Discuss signs and symptoms of worsening infection that require urgent medical attention (increased pain, fever, chills, spreading redness).
Advise on preventing recurrent abscesses (good hygiene practices, addressing underlying medical conditions).
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of skin abscesses