The patient has a subungual abscess. You can’t see it well because of the fake nail. It’s not a felon (yet). Felons affect the finger pad; this pocket of pus is confined to the tip (extending from under the nail).
The treatment is to remove the nail (or the tip of the nail) after doing a digital block. Usually no I&D needs to be done because the pocket will just pop. Like most abscesses, antibiotics are not needed.
I numbed up the finger. When I went to work on the nail, the nail basically fell off on its own because there was so much pus under it. It smelled up the room, which is very unusual for a little finger abscess.
I committed two silly minor infractions. First – I put the patient on antibiotics because there was so much pus, which is illogical (despite the volume of pus). I sent the patient home on augmentin. The culture grew out Serratia which was resistant to augmentin, but the patient was better anyway. It reinforced the boo-boo that the abx was unnecessary.
Second, I did the abscess myself (I was in Fast Track). I should have done the abscess with a resident. I was a bad teacher, but sometimes I forget about the residents when I’m seeing patients primarily. These minor procedures are important for resident education. Sorry SK.