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<h1 class="page__title title" id="page-title">Cellulitis and Abscess Management in the Era of Resistance to Antibiotics (CAMERA)</h1> <h2>Appendix A. Skin and Soft Tissue Infection Action Plan</h2>
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</div>
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<div class="field field-name-ahrq-generic-body field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p><strong>Date: ___________________</strong></p>
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<p><strong>Allergies:</strong></p>
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<p><strong>Notes:</strong></p>
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<p><strong>Fever:</strong></p>
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<blockquote><p>History of Fever: Y N<br />
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Temperature at Visit: ________ ° 1 C ___ 2 F ___</p></blockquote>
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<p><strong>Vital Signs:</strong></p>
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<blockquote><p>Pulse –<br />
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Blood Pressure –</p></blockquote>
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<p><strong>Risk for MRSA:</strong></p>
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<table border="0" cellpadding="2" cellspacing="0" width="90%">
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<tbody>
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<tr>
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<td scope="row">__ Recent hospitalization <em>(within 1 month)</em></td>
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<td>__ Other skin condition__________________</td>
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</tr>
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<tr>
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<td scope="row">__ Family Member with MRSA <em>(in last 6 months)</em></td>
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<td>__ Immunocompromized:________________</td>
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</tr>
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<tr>
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<td scope="row">__ Sport team: ____________________________</td>
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<td>__Diabetes</td>
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</tr>
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<tr>
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<td scope="row">__ History of MRSA: __________________</td>
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<td>__Other risk factor:_____________________</td>
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</tr>
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<tr>
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<td scope="row">__Excema</td>
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<td>__None of the above</td>
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</tr>
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</tbody>
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</table>
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<p><strong>Number of Infected Lesions:</strong> ________</p>
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<table border="1" cellpadding="2" cellspacing="0" width="80%">
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<tbody>
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<tr>
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<th scope="col"> </th>
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<th scope="col">Site 1</th>
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<th scope="col">Site 2</th>
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<th scope="col">Site 3</th>
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<th scope="col">Site 4</th>
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</tr>
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<tr>
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<td colspan="5" scope="row">General description of infection</td>
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</tr>
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<tr>
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<td scope="row">Duration (days)</td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">Location <em>(face, neck, trunk, arm, hand, buttock, leg, foot, elsewhere)</em></td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">Size (cm, greatest diameter)</td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">Red (erythema)</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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</tr>
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<tr>
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<td scope="row">Swollen (edema)</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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</tr>
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<tr>
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<td scope="row">Warm</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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</tr>
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<tr>
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<td scope="row">Painful/Tender</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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</tr>
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<tr>
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<td scope="row">Other Findings</td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td colspan="5"><strong>Is it an abscess?</strong></td>
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</tr>
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<tr>
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<td scope="row">Fluctuant</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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</tr>
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<tr>
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<td scope="row">Yellow or White Center</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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</tr>
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<tr>
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<td scope="row">Central Point or “Head”</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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</tr>
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<tr>
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<td scope="row">Draining pus (discharge, purulent)</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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</tr>
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<tr>
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<td scope="row">Other Findings</td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td colspan="5" valign="top"><strong>Was it Drained?</strong></td>
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</tr>
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<tr>
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<td scope="row">I&D</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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</tr>
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<tr>
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<td scope="row">Needle Aspiration</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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</tr>
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<tr>
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<td scope="row">Manually Expressed</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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</tr>
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<tr>
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<td scope="row">Packed</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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</tr>
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<tr>
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<td scope="row">Referred for Further Management to:</td>
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<td colspan="4" valign="top"> </td>
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</tr>
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<tr>
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<td colspan="5"><strong>Was a Culture and Sensitivity Analysis Obtained?</strong></td>
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</tr>
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<tr>
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<td scope="row"> </td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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<td>Y N</td>
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</tr>
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</tbody>
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</table>
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<p><strong>Summary of other sites if more than four:</strong></p>
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<p><strong>Antibiotic:</strong></p>
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<blockquote><p>___ None<br />
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___ Empiric Treatment for suspected MRSA<br />
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<em>(</em>e.g., <em>clindamycin, doxycycline, minocycline, trimethoprin-sulfamethoxazole)</em></p>
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<p> Rx: ____________________________________</p>
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<p>___ Empiric Treatment for non-MRSA or Streptococcus <em>(</em>e.g., <em>beta lactam)</em></p>
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<p> Rx: ____________________________________</p>
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<p>___ Other Rx: ____________________________________</p>
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</blockquote>
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<p><strong>Patient Followup:</strong></p>
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<blockquote><p>___ PRN<br />
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___ Scheduled for _______ days</p></blockquote>
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<p><strong>Patient Education:</strong></p>
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<blockquote><p>___ CDC Information Sheet<br />
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___ Other: __________________________</p></blockquote>
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<p><strong>CPT Codes:</strong><br />
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10060 – Simple or single I&D or needle aspiration<br />
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10061 – Complicated or multiple I&D or needle aspiration</p>
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<hr />
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<p><strong>ICD-9 Codes:</strong><br />
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041.1 Staphylococcus infection<br />
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680.X<a href="#ast">*</a> Carbuncle or furuncle<br />
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681.00 Cellulitis or abscess of finger<br />
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681.10 Cellulitis or abscess of the toe<br />
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681.9 Cellulitis or abscess of unspecified digit<br />
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682.X* Other cellulites or abscess<br />
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<strong><a id="ast" name="ast">*</a> X=.0 face, .1 neck, .2 trunk, .3 arm, .4 hand, .5 buttock, .6 leg, .7 foot, .8, head, .9 elsewhere</strong></p>
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<hr />
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<p><strong>Follow-up:</strong></p>
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<blockquote><p>___ Final Culture Result: ____________________________________ Date: _______________<br />
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___ Patient Notified: Y N ; Date: __________________<br />
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___ New Rx: __________________________<br />
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___ Other: __________________________</p></blockquote>
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<p class="size2"><a href="/research/findings/final-reports/mrsa/nc_mrsa.html#contents">Return to Contents</a><br />
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<a href="/research/findings/final-reports/mrsa/nc_mrsaapb.html">Proceed to Next Section</a></p>
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</div></div></div><div class="field field-name-field-last-reviewed field-type-datestamp field-label-hidden">
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<div class="field-items">
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<div class="field-item even">
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Page last reviewed <span class="date-display-single" property="dc:date" datatype="xsd:dateTime" content="2014-10-01T00:00:00-04:00">October 2014</span> <br />Page originally created September 2012 </div>
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</div>
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<div id="block-ahrq-citation" class="block block-ahrq first odd">
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Internet Citation: Appendix A. Skin and Soft Tissue Infection Action Plan. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/research/findings/final-reports/mrsa/nc_mrsaapa.html<div class="citation-flag"> </div> </div> <!--</div>--> <div class="footnote"> <p> The information on this page is archived and provided for reference purposes only.</p> </div> <p> </p> </div> </div></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div>
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