Identification Data
Name: Mdm R
Age: 61
Race: Malay
Marital Status: Married
Date of Admission: 1 March 2011
Date of Clerking: 1 March 2011
Co-morbid: 1) Diabetes Mellitus for 2 years
2) Hypertension for 3 years
3) Right eye cataract
Chief Complaint
This patient is referred from Hospital Selama with the chief complaint of swelling of the left hand and fever 14 days prior to admission.
History of Present Illness
The patient was well until 14 days ago when she noticed that her left hand started to swell at the left wrist region. She also complained of pain on that swollen area together with redness. The swelling gradually increases in size and the pain became worse but there was no pus noted. She started to have fever right after the swelling started. It was a high grade fever as it is associated with chills and rigors. The fever was relieved temporarily with medication. A week after that, she was taken to Hospital Selama and she was admitted there for 7 days. Within these days, she claimed that the pain became colicky in nature. She also had diarrhea for 5 days with frequency of 3 to 4 times per day. The stool was watery with no blood or mucus. She also complained of vomiting 2 to 3 times a day in the ward for 3 days since the day she was admitted. The vomitus was food particles with no mucus or blood. Her appetite reduced since then. At that hospital she was treated as a patient with acute gastroenteritis and left hand abscess. She was on IV cloxacillin 500 QID for 4 days. Incision and drainage was done yesterday with 30cc of pus being drained but today at Hospital Selama there was still pus discharge noted and it was tracked up to the proximal part of the left wrist. She was then referred to Hospital Taiping on the same day for further management.
Past Medical/Drug History
- The patient is a known case of diabetes mellitus for 2 years. She is on gliclazide 80mg bd and metformin 1g bd.
- She is also hypertensive, diagnosed 3 years ago. She is on perindopril 8mg, lovastatin 20mg, HCT2 37.5mg.
- She refused to go for follow up at Klinik Kesihatan Sungai Bayu in Selama and she is not compliant to her medication.
- The patient is also known to have right eye cataract and it was removed in October 2010.
Family History
· There is no significant family history.
Drug and Allergy History
Besides the medications for DM and hypertension, she is not on any other medication. She is not allergic to any drugs or food.
Social History
· She is a housewife.
· She does not smoke or consume alcohol.
· She eats normal balanced diet.
· Her husband is a retired army. She has three daughters and all are married.
· She lives in Kampung Seri Raja, Selama with her husband.
Clinical examination
Her weight was 82 kg and her height 157cm.
On general examination, the patient looked lethargic but she was not in respiratory distress. There was no sign of jaundice. There was a slight conjunctival pallor on both eyes. There is slight clouding on the lens of her right eye. There was no pitting edema on both legs. Her blood pressure was 150/90 mmHg. Her pulse rate was 82 beats per minute. The rhythm is regular and the volume is good with no special characteristics. Her random blood sugar was 12mmol/L. She was afebrile.
Her thyroid and her breasts were normal.
Cardiovascular examination revealed that both heartsound were normal and there was no murmur.
Respiratory examination revealed that air entry was good bilaterally. There was no crepitation or rhonchi.
Her abdomen was slightly distended. The umbilicus is centrally located and flat. There is no surgical scar or dilated veins. On palpation, the abdomen is soft, not tender and no mass felt.
On examination of her left hand, there is a swelling with pus discharge and redness on her left wrist extending up to the proximal part. The size is 3x5cm. The shape is rounded. On palpation, there is pus discharge noted. It is warm and tender.
Clinical Diagnosis
Left hand abscess
Investigations
· The full blood count: WBC is raised.
· Urine FEME: no significant findings.
· Urinalysis:
1. Ketones = 3+ (higher than normal)
2. Glucose = +-
3. Protein = 1+ (higher than normal)
4. Urobilinogen = 1+ (higher than normal)
· Renal Function Test: sodium and potassium levels are normal.
Management
Monitor the vital signs of the patient, especially her blood pressure and body temperature. Monitor her blood glucose level. Incision and drainage should be done for the abscess. Continue IV antibiotics.
Discussion
An abscess (Latin: abscessus) is a collection of pus (dead neutrophils) that has accumulated in a cavity formed by the tissue in which the pus resides on the basis of an infectious process (usually caused by bacteria or parasites) or other foreign materials (e.g., splinters, bullet wounds, or injecting needles). It is a defensive reaction of the tissue to prevent the spread of infectious materials to other parts of the body. One example of an abscess is a BCG-oma, which is caused because of incorrect administration of the BCG vaccine.
The organisms or foreign materials kill the local cells, resulting in the release of cytokines. The cytokines trigger an inflammatory response, which draws large numbers of white blood cells to the area and increases the regional blood flow.
The final structure of the abscess is an abscess wall, or capsule, that is formed by the adjacent healthy cells in an attempt to keep the pus from infecting neighboring structures. However, such encapsulation tends to prevent immune cells from attacking bacteria in the pus, or from reaching the causative organism or foreign object.
Abscesses must be differentiated from empyemas, which are accumulations of pus in a preexisting rather than a newly formed anatomical cavity.
Wound abscesses do not generally need to be treated with antibiotics, but they will require surgical intervention, debridement and curettage.
he abscess should be inspected to identify if foreign objects are a cause, which may require their removal. If foreign objects are not the cause, a doctor will incise and drain the abscess and prescribe painkillers and possibly antibiotics.
Surgical drainage of the abscess (e.g., lancing) is usually indicated once the abscess has developed from a harder serous inflammation to a softer pus stage. This is expressed in the Latin medical aphorism: Ubi pus, ibi evacua.
In critical areas where surgery presents a high risk, it may be delayed or used as a last resort. The drainage of a lung abscess may be performed by positioning the patient in a way that enables the contents to be discharged via the respiratory tract. Warm compresses and elevation of the limb may be beneficial for a skin abscess.
s Staphylococcus aureus bacteria is a common cause, an anti-staphylococcus antibiotic such as flucloxacillin or dicloxacillin is used. With the emergence of community-acquired methicillin-resistant staphylococcus aureus MRSA, these traditional antibiotics may be ineffective; alternative antibiotics effective against community-acquired MRSA often include clindamycin, trimethoprim-sulfamethoxazole, and doxycycline. These antibiotics may also be prescribed to patients with a documented allergy to penicillin. (If the condition is thought to be cellulitis rather than abscess, consideration should be given to possibility of strep species as cause that are still sensitive to traditional anti-staphylococcus agents such as dicloxacillin or cephalexin in patients able to tolerate penicillin). It is important to note that antibiotic therapy alone without surgical drainage of the abscess is seldom effective due to antibiotics often being unable to get into the abscess and their ineffectiveness at low pH levels. Whilst most medical texts advocate surgical incision some medical doctors will treat small abscesses conservatively with antibiotics.
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