MDM - Mastitis

[##]-year-old [breastfeeding] female with [redness/irritation/swelling] of the [right/left/bilateral] breast(s) with history and exam consistent with likely mastitis.

Initial considerations in this patient included mastitis, cellulitis, mechanical irritation of the breast, systemic infectious processes, and necrotizing soft tissue infections among others.

Patient presented with [erythema/swelling/tenderness] of the [right/left/bilateral] breast with associated [fever/chills/flu-like symptoms] concerning for mastitis [in the setting of breastfeeding].  Labs [were/were not] obtained in the evaluation of this patient [based on absence of response to antibiotics after 2 days, recurrent episode of mastitis, hospital acquired mastitis, reported allergy to standard antibiotic therapy, or severe or unusual case/absence of concerning features].  [Labs were noted to be unremarkable/notable for specify.]  A [bedside/formal] ultrasound was obtained with [no evidence of concurrent abscess/evidence of superficial/deep abscess measuring ## cm].  [Given superficial/deep nature of abscess, a needle aspiration was performed under ultrasound guidance/surgery was consulted for further management.]

[The site of cellulitis was marked prior to discharge from the ED with strict return precautions given for evidence of worsening infection.]  We discussed return precautions, specifically for evidence of worsening infection, treatment with [Dicloxacillin/Cephalexin/Clindamycin/Augmentin] and symptomatic treatment, and follow up with primary care doctor within 2-3 days for further evaluation of response to therapy, and the patient demonstrated understanding and agreement.  Prior to discharge, we emphasized the importance of continuing to breastfeed while on antibiotics, and the patient demonstrated understanding and agreement with this recommendation.

Discharge Instructions - Cellulitis

As discussed in the Emergency Department prior to discharge, you have been diagnosed with cellulitis of the [location].  Cellulitis is an infection of the skin. It usually looks like a bright pink or red patch of skin, and it is very warm to the touch.

It is important for you to monitor the size of the cellulitis after you begin your antibiotics.  To do this, you can take a regular pen and draw a line around the area of redness if this was not done in the Emergency Department.  Look at the wound every day to observe whether it is getting bigger (crossing beyond the pen line) or smaller.  The size of the red area should decrease every day.  Whilst it might become a little bigger on day one of the antibiotics, the redness should become smaller by day two.

Make sure that you take your prescribed antibiotics as directed, for the full course (don’t stop early).

Another way to help the cellulitis to heal is to keep it elevated as much as you can.  For example, if the cellulitis is on your forearm, keep your arm up as much as you can (like you are the queen and about to wave at your subjects), so that gravity can drain the swelling away.  If the cellulitis is on your leg, you can prop up your leg on a chair when you are sitting down, or put pillows under your leg when you are sleeping.  This helps to remove the inflammation from around the area.  Don’t use the limb excessively, to allow it to heal (i.e. no long walks if the cellulitis is on your leg).

Return to the Emergency Department if the pink or red area is not smaller by day two after starting antibiotics, you see a red streak going up your arm or leg after starting antibiotics, you develop a new fever (≥38.0 °C or 100.4 °F) or a fever that hasn’t resolved by day two of antibiotics, or for any new or concerning symptoms.

Discharge Instructions - Mastitis

As discussed in the Emergency Department prior to discharge, you have been diagnosed with mastitis.  Mastitis is an infection in the breast tissue that most commonly occurs in breastfeeding women.  It usually involves significant swelling as an infection occurs in the breast ducts that drain milk.

Mastitis can occur in the setting of inflammation and obstruction of breast ducts without infection, but it is more commonly associated with a bacterial infection.  Bacteria (usually Staphylococcus aureus) commonly enter through a crack or break in the skin or nipple.  In many cases the bacteria causing mastitis is from the mouth of the breastfeeding infant.

It is important that you continue to breastfeed through mastitis, as this will help drain blocked breast ducts and decrease inflammation and swelling.  Your infant is extremely unlikely to catch this infection by continuing to breastfeed and the benefits of breast milk far outweigh any risks.  If you choose not to breastfeed your infant, it is important that you continue to pump breast milk to at least promote drainage.

Make sure that you take your prescribed antibiotics as directed, for the full course (don’t stop early).

Acetaminophen (also known as Tylenol) an over-the-counter medication can assist with discomfort, and is safe to take while breastfeeding according to the dosing instructions on the package.  You can also massage the breast after feedings to help decrease swelling.  You can also apply ice to the breast after feedings for about 10 minutes to help with discomfort and swelling.

Return to the Emergency Department if the pink or red area on the breast is not smaller by day two after starting antibiotics, you see a red streak going up the breast after starting antibiotics, drainage of pus or foul smelling fluid from the nipple, you develop a new fever (≥38.0 °C or 100.4 °F) or a fever that hasn’t resolved by day two of antibiotics, or for any new or concerning symptoms.

MDM - Periorbital Cellulitis

[##]-year-old [male/female] with [periorbital/eye redness] with history and exam consistent with likely [right/left]-sided periorbital cellulitis.

Initial considerations in this patient included periorbital and orbital cellulitis, dacryocystitis, allergic reaction, various etiologies of conjunctivitis, blepharitis, orbital tumors, cavernous sinus thrombosis, chalazion, stye, herpes simplex, and contact dermatitis amongst others.

Patient presented with redness, [tenderness,] and swelling of the eyelids and periorbital area for the past [time frame].  No evidence of proptosis, loss of extraocular muscle function, pain with extraocular movements, diplopia, or vision loss to suggest orbital cellulitis or mass effect on exam in the ED.  Based on findings on exam, further imaging [was deemed unnecessary at this time/was obtained and noted to be without evidence of orbital cellulitis or other deep space infections].  No significant conjunctival injection, irritation, or discharge noted on exam to suggest conjunctivitis.

Prior to discharge, we discussed plan for treatment with antibiotics and stressed the importance of completing the full course of antibiotics with the [patient/parents].  We discussed return precautions, specifically for evidence of worsening infection or orbital cellulitis, and follow up with primary care doctor within 2-3 days for further evaluation, and the [patient/patient’s parents] demonstrated understanding and agreement with this plan.

Ultrasound - Soft Tissue (Abscess)

Ultrasound: Soft Tissue

A focused soft tissue ultrasound of the [location] was performed by [myself/Dr. Resident under my supervision/independently with images reviewed by myself] in the evaluation of patient with [describe complaint].  

Long and transverse views of the [location] were obtained.  Fluid collection consistent with an abscess was noted with a size of [## x ## cm].  Cobble-stoning suggestive of cellulitis [was/was not] present.  A foreign body [was/was not] noted.

IMPRESSION:

Findings consistent with an abscess measuring [## x ## cm] to the [location].

https://www.wikem.org/wiki/Ultrasound:_Soft_tissue

MDM - Animal Bite

[##]-year-old [male/female] with [animal] bite to the [location] with history and exam consistent with [low/moderate/high] risk for infection.

Initial consideration in this patient included risk for deep space infection, tendon injury, risk for rabies, risk for tetanus, and penetration into joint cavity amongst others.

Patient presented with [abrasions/lacerations] to the [location with/without] evidence of purulent drainage or significant contamination to the wounds.  Patient noted to have full active and passive range of motion of the [location] despite pain.  Patient noted to have [no] evidence of [specify] tendon injury.  Plain films were obtained [with/without] evidence of foreign body.  Wounds cleaned and dressed in the ED prior to discharge. 

Tetanus status was [noted to be up to date/unknown with patient vaccinated in the ED] prior to discharge.  Risk of rabies was considered [a possibility given unknown vaccination status of the animal that bit the patient/unlikely given report of vaccinated animal with no evidence of unusual or aggressive behavior].  Administration of rabies immunoglobulin and vaccine [felt to not be indicated at this time/performed in the ED prior to discharge with discussion of appropriate follow up for additional doses of rabies vaccine prior to discharge].

Discussed discharge with [analgesics/prophylactic antibiotics], and follow up with [primary care doctor/Orthopedics/Occupational Health] in [48 hours/2-3 days], and the patient demonstrated understanding and agreement.

MDM Cellulitis

[##]-year-old [male/female] with [redness/irritation] with history and exam consistent with likely cellulitis of the [location].

Initial considerations in this patient included cellulitis, erysipelas, lymphangitis, abscess, contact dermatitis, septic arthritis, and necrotizing soft tissue infections among others.

Patient presented with erythema, warmth and swelling to the [location] consistent with cellulitis.  Patient [denies/reports/is noted to have] associated fever [without other findings suggestive of sepsis].  No evidence of associated joint swelling or painful range of motion to suggest septic arthritis at time of ED evluation.  No evidence of fluctuance [or ultrasound evidence] suggestive of abscess.  Considered necrotizing soft tissue infectious process unlikely in patient without description of rapidly progressive infection, pain out of proportion to exam, [evidence of gas formation on x-ray/ultrasound,] crepitus, hemorrhagic bullae, or significant systemic infectious symptoms.  Considered admission [unnecessary based in patient with no evidence of significant systemic infectious process and good outpatient follow up/and discussed admission with Internal Medicine who evaluated the patient in the ED and agreed with need for admission/felt outpatient treatment was appropriate and arranged follow up]. 

[The site of cellulitis was marked prior to discharge from the ED with strict return precautions given for evidence of worsening infection.]  Prior to discharge, we discussed return precautions, specifically for evidence of worsening infection, treatment with antibiotics, and follow up with primary care doctor within [2-3 days/one week] for further evaluation, and the patient demonstrated understanding and agreement.

MDM - Sepsis

[##]-year-old [male/female] with [altered mental status/fever/weakness/etc.] with history and exam consistent with sepsis from [unclear infectious source/pneumonia/urinary tract infection (UTI)/etc.].

Patient felt to have symptoms concerning for a potential infection based on [fever (temperature ≥100.4°F)/elevated heart rate (>90)/elevated respiratory rate (>20 or PaCO₂ < 32 mmHg)] noted at time of initial triage.  Labs were obtained to include a lactate level, CBC, and blood cultures, and were notable for [leukocytosis (>12,000/mm³)/leukopenia (<4,000/mm³)/bandemia (>10% bands)] concerning for systemic inflammatory response (SIRS).  The patient was noted to have an initial lactate that was [within normal limits/minimally/moderately/significantly elevated]. 

We considered possible respiratory sources for infection and obtained a chest x-ray [and additional imaging], which was [notable for pneumonia/unremarkable].  We considered possible urinary sources of infection and obtained a urinalysis and urine culture, which was [notable for findings suggestive of a UTI/unremarkable].  We considered possible soft tissue sources for infection [and noted findings on the LOCATION consistent with cellulitis/abscess/fasciitis].  We considered [additional infectious sources] and obtained [additional testing] which was [notable for FINDING/noted to be unremarkable].

Based on findings SIRS criteria and [presumed infectious source], the patient was felt to meet criteria for sepsis.  Broad spectrum antibiotic coverage was initiated within 3 hours of ED triage with [antibiotics used].  Resuscitation with crystalloids IV [was initiated as a 30 mL/kg bolus/was initiated as ### mL boluses due to patient’s history of heart failure/etc.].  Vasopressors [were/were not] felt to be indicated due to [ability/inability] to maintain mean arterial pressure (MAP) of ≥65 mmHg [after/despite] crystalloid boluses.  The patient was felt to have [no] evidence of septic shock based on [no/vasopressor requirement to maintain MAP ≥65 mmHg and/or serum lactate >2 mmol/L despite resuscitation with crystalloids/without evidence of hypovolemia].

Patient noted to have a qSOFA score of [##] suggestive of [<1 patient who is not high risk for poor outcome/≥2 high risk of poor outcome], so the patient was felt to meet criteria for admission to [general floor with telemetry/step down unit/ICU].  We discussed presumed diagnosis of [unknown/infectious source] with findings concerning for sepsis with the [patient/family/caregiver].  We discussed plan for admission for further treatment, and the [patient/family/caregiver] demonstrated understanding and agreement with this plan.

We discussed the case with Dr. [Name] who agreed with need for admission to the [general floor with telemetry/step down unit/ICU] for further treatment of [infection and sepsis].

https://www.mdcalc.com/sirs-sepsis-septic-shock-criteria

https://www.mdcalc.com/qsofa-quick-sofa-score-sepsis

MDM - Abscess

[##]-year-old [male/female] with history and exam consistent with abscess to the [location].

Initial consideration in this patient included abscess, cellulitis, cyst, necrotizing fasciitis, and other deep space infections among others.

Patient presented with complaint of [boil/swelling/redness], and was noted to have [fluctuant mass palpable on exam/bedside ultrasound evidence] consistent with abscess.  Abscess felt to be amenable to incision and drainage (I&D) based on size on duration of symptoms.  After discussion of risks, benefits, and alternatives to I&D, the patient provided [verbal/written] consent to the procedure as noted above.  The abscess cavity was evacuated and probed thoroughly without evidence of significant depth or extension.  The abscess cavity [was/was not] packed [due to small size of the cavity after drainage].  The patient tolerated the procedure well without significant complications as noted above.

Antibiotic treatment was felt [to be indicated based on the size of the abscess and the patient’s comorbid conditions/to not be indicated at this time based on appropriate drainage and packing of the patient’s abscess].  Prior to discharge, we discussed return precautions, treatment, and follow up with primary care doctor within one week for further evaluation, and the patient demonstrated understanding and agreement with this plan.