CLINICAL CASE SCENARIO

26 year old male patient with no significant past medical history presents to the clinic complaining of three painful bumps on his right bicep and underarm for one week. 

QUESTIONS TO ASK

• Have you been outside recently?
• Do you remember being bit by a bug?
• Have you changed the type of soap, lotion, or detergent you use recently?
• Have you hurt the affected area in the past or recently?
• Are the bumps itchy?
• Is the pain constant, worse with movement, or comes and goes?
• Have you tried anything to alleviate the symptoms?
• Has this ever happened to you before?

HISTORY OF PRESENT ILLNESS

• Constant sharp pain
• Not pruritic
• No bug bites
• No edema, erythema, ecchymosis
• No trauma to the area
• No change is soap or lotions
• No history of STIs
• Has not taken anything to alleviate the pain
• No joint pain
• No fever, body aches, chills, headache, nausea, vomiting, diarrhea, constipation
• No chest pain or shortness of breath
• Never happened before

PAST MEDICAL HISTORY

• None

CURRENT MEDICATIONS

• None

ALLERGIES

• NKDA

SOCIAL HISTORY

26 year old male patient resides in Middle Village, Queens in an apartment with his roommate. He currently works from home as an accountant. Patient states he eats balanced meals in carbs, protein, and vegetables but is minimally active due to his occupation. Patient endorses drinking occasionally for social events and denies a history of smoking and drug use. 

REVIEW OF SYSTEMS

• General  – Denies chills, fever, lightheadedness.
• ENT  – Denies ear pain, sore throat, swollen glands, changes in vision.
• Cardiovascular  – Denies chest pain, palpitations, shortness of breath. 
• Gastrointestinal  – Denies abdominal pain, diarrhea, constipation, nausea, vomiting. 
• Skin  – Presence of 2 painful indurated bumps in the right underarm and 1 painful indurated bump on the right inner arm. Denies rash, erythema, edema.
• Neurologic  – Denies dizziness, headache, numbness, tingling. 

PHYSICAL EXAM

• Vital Signs – HR 71 bpm, BP 134/88, R 18, T 97.7
• General – Alert, well developed, well nourished, in no acute distress.
• Eyes – pupils equal, round, reactive to light and accommodation.
• Heart – no murmurs, regular rate and rhythm, S1, S2 normal.
• Lungs – clear to auscultation bilaterally.
• Musculoskeletal – no ecchymosis, edema, erythema, deformities, acute abnormality notes, pain. Full range of motion with 5/5 strength. 
• Skin – Right Underarm: skin intact with no deformity. Noted 2 erythematous papules. Areas are tender to palpation. No drainage noted. Papules are indurated. Right Upper Arm: skin intact with no deformity. Noted 1 erythematous papule. Areas are tender to palpation. No drainage noted. Papule is indurated. 

DIFFERENTIAL DIAGNOSIS

• Abscess – Abscesses are collections of pus in tissue due to bacterial infection. The underarm is an area prone to infection due to moisture and skin to skin contact. Currently, the patient presents with an indurated lump that is not filled with pus. It is possible that the lump is at the early stages of infection. For this reason, the patient should be placed on oral antibiotics to resolve the abscess prior to the need for incision and drainage. 

• Furuncle – Furuncles typically present as red and painful lump due to infection of a hair follicle. This patient fits this presentation as it is a very painful lump. However, the lump was not fluctuant. This may be due to the fact that the bump is still in the early stages of infection and not filled with pus. 

• Hydradinitis Supporativa – Patient presents to the clinic with underarm bumps. Hydradinitis Supporativa should be included in the list of differential diagnoses. Hidradenitis Suppurativa presents with painful lumps due to inflammation and infection of the sweat glands. However, this is a chronic condition that enlarges, fills with pus, and may result in scarring. The patient may be continued to be monitored for this condition. But as the lumps remained isolated, few, and indurated, this condition is lower on the list of differentials. 

• Folliculitis – Patient presents with bumps in the underarm region that is prone to moisture, heat, and irritation. There is a high likelihood the patient has an infected hair follicle. However, the bumps are large, indurated, and with a dark center that does not entirely correlate with the presentation of folliculitis. Folliculitis typically appears as multiple small papules. 

• Epidermoid Cyst – And epidermoid cyst is a benign lump that is painless. As the patient presents with significant pain, this diagnosis is placed lower on the list of differentials. 

TESTS

• Skin Culture of debrided material or blood is indicated if the bumps present with severe local infection, systemic signs of infection, or failure of initial antibiotic therapy. The culture would identify the exact strain of bacteria causing the infection to guide antibiotic therapy. 

DIAGNOSIS

• Skin Abscess – Patient presents with painful lumps in both areas of hair follicles and isolated soft tissue. Patient has never experienced this before and the bumps presented acutely in the past week. Although the bumps are indurated and do not require incision and drainage, abscess is the most likely diagnosis. 

TREATMENT

• Oral Antibiotics (One of the following)
  • Clindamycin 300 mg PO q 8 hours
  • Augmentin 500 mg q 8 hours
  • Doxycycline 100 mg q 12 hours
  • Cephalexin 250 mg q 6 hours 

• Oral Pain Relief (One of the following)
  • Tylenol q 4 – 5 hours
  • Ibuprofen q 6 – 8 hours

PATIENT COUNSELING

• Instruct patient on antibiotic dosage
• Advise patient to use warm compresses 2x each day on affected area
• Recommend patient to avoid use of deodorant until completion of antibiotics 
• Have patient monitor bumps for signs of infection (pus, erythema, fever) 
• Encourage patient to return to the clinic or present to the emergency room if signs of infection present or worsen