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27/08/2022
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Upon evaluation, it becomes evident that the patient’s presentation of a furuncle accompanied by multiple smaller open lesions necessitates a broader consideration of her health status. A furuncle, as defined by Rehmus (2023), is a localized skin abscess resulting from staphylococcal infection, involving the hair follicle and surrounding tissue. Furthermore, the presence of these additional open lesions introduces a range of potential differential diagnosis, encompassing bacterial or parasitic infections, substance abuse related issues, or hygienic, nutritional, and mental well-being related challenges. It is imperative to recognize that homelessness poses various obstacles to the establishment and maintenance of healthcare and social support services.
1. Specimen Collection: a swab of the drainage should be obtained for culture and sensitivity.
2. Wound Care: cleanse and prep the patient for drainage if necessary, using a local anesthetic to reduce pain with the procedure (Rehmus, 2023). After a small incision is made, apply manual pressure to express the purulent material within (Troxell & Hall, 2023). Iodoform packing strips may be required to assist with further drainage. Leave this in place for 24-48hrs. then remove. A topical antibiotic such as clindamycin or mupirocin may be used as adjunctive therapy (Troxell & Hall, 2023).
3. Oral Antibiotics: if MRSA is suspected or cultured, treatment choices include the following:
a. Sulfamethoxazole/trimethoprim 800/160mg to 1600/320mg PO q12hrs
b. Clindamycin 300mg to 600mg PO q6-8hrs
c. Doxycycline/Minocycline 100mg PO q12hrs
4. Hygiene: the patient should cleanse the area and wash with antibacterial soap. Mupirocin should be applied twice daily to the nares for 12-30 days to provide staphylococcal decolonization.
5. Pain Management: warm, moist compress throughout the day to facilitate drainage. OTC pain medication such as Tylenol or Ibuprofen as needed.
6. Referral to Social Services: may help connect the patient to local social services, shelters, temporary housing, food, clean clothing, and access to personal hygiene facilities.
7. Patient Education: completing the complete course of antibiotics. Not sharing clothing, towels, etc. with other people. Keeping the area clean and dry. Washing with antibacterial soap.
8. Follow-Up: in 2-3 days if no improvement despite antibiotic use or continued drainage, increased redness, fever, or other worrisome symptoms. Follow-up in 1-2 weeks to ensure resolution and improvement of furuncle and other skin lesions.
Given the patient’s history of homelessness and sleeping in a park, her living situation exposes her to unsanitary conditions and increases her risk of developing skin infections and lesions. The presence of a furuncle on her shoulder and additional small open lesions indicates that she is indeed dealing with skin health issues.
What is a Furuncle? According to (InformedHealth.org [Internet]., 2018), a boil (furuncle) is a pus-filled bump in the skin that is caused by a bacterial infection. It’s a bit like a very big yellow pimple, but it’s deeper in the skin and hurts a lot more.
Furuncle is typically caused by the bacterium Staphylococcus aureus. The infection occurs when bacteria enter the hair follicle or sweat gland, leading to inflammation, pus accumulation, and the formation of a painful lump. In the case of the patient, her exposure to heat, humidity, and unclean environments likely contributes to the development and worsening of these infections.
The patient holds the belief that the furuncle has been caused by a spider bite. Initially, distinguishing between spider bites and furuncles can be challenging, as both often manifest as red and slightly swollen areas. However, as time progresses, furuncles typically evolve, becoming increasingly painful due to bacterial infection and the accumulation of pus. They also tend to feel warm to the touch.
According to (Mayo Clinic, n.d.), typically, a spider bite looks like any other bug bite — a red, inflamed, sometimes itchy or painful bump on the skin — and may even go unnoticed. Harmless spider bites usually don’t produce any other symptoms.
My initial assessment will include a thorough head-to-toe examination of her skin, paying special attention to the areas with lesions and assessing for signs of infection, inflammation, redness, warmth, and tenderness. Given her living situation and the risk of skin infections, it’s important to evaluate the extent of her skin problems and identify any other potential health issues that might arise from her lifestyle.
I am also very concerned about her other open lesions, as they could be indicative of underlying dermatologic skin infections that are worsening. This deterioration may be attributed to the patient’s inadequate hygiene practices and living conditions. One potential diagnosis is an Atopic dermatitis infection, which could be contributing to the presence of these open lesions. Poor hygiene, scratching and exposure to contaminants in the environment are also contributing factors in her case.
As part of the comprehensive assessment, we will also conduct cultures of the lesions to identify the presence of Methicillin-resistant Staphylococcus aureus (MRSA). Treatment for the open lesions will be contingent on the culture results.
Plan:
The initial step would be to reach out to a relevant foundation, such as “The Health Care for the Homeless” project, which is supported by the Robert Wood Johnson Foundation. This approach aims to seek guidance on acquiring supplementary assistance and housing options for the patient. Considering the necessity for treatment and recognizing the potential challenges posed by her homelessness, including non-compliance with medication for addressing the infection or other underlying dermatological issues, seeking professional guidance becomes crucial.
Treatment:
In the event that the furuncle becomes infected, a drainage procedure may be necessary in our office, along with potential wound care as required. The patient will be initiated on a regimen of oral antibiotics. As stated in the study by Lin et al. (2018), the recommended antibiotics for treating an infected furuncle include Ciprofloxacin 500 mg orally every 12 hours for a duration of 7–14 days.
Moreover, the patient will be provided with a topical antibiotic ointment, such as fusidic acid (sodium fusidate) cream or ointment 2%, to be applied to the affected area once or twice a day.
Regarding any open lesions, treatment will be contingent on the results of the cultures. While awaiting the culture outcomes, the lesions will be maintained in a clean state using normal saline, and they will be covered with sterile 4×4 gauze.
To comprehensively evaluate the patient’s condition, we will conduct a complete blood count (CBC), comprehensive metabolic panel (CMP), and hemoglobin A1c test to effectively rule out diabetes.
Education:
Patient will be educated on proper wound care, hygiene, and how to prevent future infections. Emphasize the importance of not picking at or scratching the lesions.
Follow-up:
A follow-up appointment will be schedule to monitor the progress of the furuncle and any other skin issues. And medication adjustment will be tailored accordingly.
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