Quote from ilovensg
I'm a new FNP APRN and about to start my first job in an outpatient office. I'm putting my pride away and hoping I can ask some scenario-based questions and get some answers as what would you do?
Make sure you identify a mentor or mentors and utilize them frequently. Good luck.
Quote from ilovensg
Patient comes in with an abscess and is on coumadin. What antibiotic would you prescribe empirically? Normally I'd choose Bactrim or doxycycline...however these affect the INR? Would you prescribe these medications and just check the INR more frequently or prescribe another medication? If so, how often would you check the INR? Otherwise, would you use clindamycin? Lastly, would you have them follow up in like 2 days? Thanks in advance!
As a generalized FYI, make sure you check with your office protocol and the other providers in your clinic before you engage in invasive procedures. You need to have on-hand supervision if you are new to a procedure and you need to have emergency coverage if a complication arises.
For uncomplicated cutaneous abscess the treatment of choice is I&D without subsequent abx coverage. However, if this patient is anti-coagulated you will likely not be handling an I&D on the initial visit. Be very careful with novels here because I have seen providers do minor surgical procedures in clinic because they checked for coumadin but not a novel and run into trouble. Be very aware of your knowledge of the adjacent anatomy as well.
Many offices don't do I&Ds at all, they refer out to either the ED or general surgery/derm consult.
If there is sign of systemic infection then ED may be appropriate.
This leaves you two options: abx or referral. Either is a valid option. Your abx choice will be based on your individual patient, their risk factors, and your local bacteriogram. Keflex is the cellulitis abx of choice but with a collected abscess you may want to cover MRSA which leave you Doxy and Bactrim DS. Both can safely be used in most situations (be aware of allergies and renal function). If the patient is on coumadin then consider a 1-2 dose hold when starting abx (1 for doxy, 2 for bactrim is generally safe). Get a baseline INR. Monitor INR every 3-5 days after starting treatment.
Cellulitis and abscesses are normally a 72 hour follow-up for me. Mark the borders.