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Abstract: A 30-year-old Ms. Li was admitted to the hospital with a localized redness and swelling with pain in her left calf for several hours mainly due to an abrasion, which the patient indicated was caused by an abrasion. Through the patient’s symptoms and MRI findings, an abrasive hematoma was diagnosed. After communicating with the patient about her condition, she underwent hematoma incision and drainage, and post-operative medication for anti-inflammation and analgesia.
Basic information】Female, 30 years old
Disease Type】Abrasion hematoma
Hospital】The First Affiliated Hospital of Kunming Medical University
Date of consultation】March 2022
Treatment plan】Surgical treatment (hematoma incision and drainage) + medication (cefixime capsule + ibuprofen extended-release capsule)
Treatment period】7 days in hospital
Treatment effect] The patient’s hematoma was reduced, and the symptoms of redness and pain were relieved.
I. Initial consultation
The patient, Ms. Li, came to our hospital and reported that she accidentally rubbed herself while riding an electric bicycle and did not care at that time, but a large hematoma bulged up in a short time. The patient’s injury was carefully examined: a hematoma of about 5cmx3cm in size was seen locally on the left calf, and the calf was obvious in terms of tenderness and pressure pain, with abrasions in other places. The patient’s family was asked to take the patient for MRI examination of the left lower extremity. The examination suggested that a pike shaped iso-T1 signal shadow with patchy slightly high signal and mixed signal shadow in T2 was seen in the left posterior calf muscle group, and the pressure lipid image showed high and low mixed signal, and the boundary with the surrounding structures was not clear in MRI. Based on the patient’s symptoms and the examination results, the patient was initially diagnosed as an abrasive hematoma, and was admitted to the hospital for treatment.
II. Treatment history
According to the patient’s specific condition, it was decided to adopt hematoma incision to drain the stagnant blood, and postoperative application of cefixime capsules for antibacterial and anti-inflammatory purposes and ibuprofen extended-release capsules for analgesia. After communicating with the patient and his family about the specific condition and treatment plan, the patient expressed his willingness to actively cooperate with the treatment.
Before surgery, routine blood tests, C-reactive protein, liver and kidney function, coagulation function, syphilis spirochete antibody test and hepatitis B two-to-one were performed to determine that the patient had no bleeding tendency or blood-borne diseases. After assessing the patient’s general condition, hematoma incision and drainage was performed, and aseptic operation was strictly carried out. After the operation, standardized antibacterial anti-inflammatory and analgesic treatment was given, and cefixime capsules and ibuprofen extended-release capsules were administered orally.
III. Treatment effect
After hematoma incision and drainage, the patient’s left calf hematoma was significantly reduced, and the local redness, swelling and pain were also relieved. The patient’s wound was examined 7 days after hospitalization, and no infection such as redness, swelling, rupture, or pus flow was observed. After discussion, the patient and his family wanted to be discharged to recuperate at home, and in view of the patient’s condition, no special discomfort was complained, so the patient was discharged, and the patient was instructed to take medication regularly after discharge to consolidate treatment.
IV. Notes
We are glad that the patient’s adverse symptoms gradually disappeared after active treatment. However, it is recommended that after discharge, patients should still pay attention to rest, avoid heavy physical labor or strenuous exercise; pay attention to wound care, avoid water, scratching stimulation, etc., to avoid inducing infection, which is not conducive to recovery; and pay attention to a reasonable diet, avoid eating too much spicy and stimulating, greasy food; ensure regular work and rest and sufficient sleep, avoid frequent late nights; keep a relaxed mood, avoid mental stress. If abnormal symptoms occur, go to the hospital in time to improve the relevant examination, clarify the diagnosis of the cause, and actively treat.
V. Personal insight
Abrasions can cause a variety of conditions, such as this patient’s left calf hematoma formation due to abrasion. In daily life, attention should be paid to avoid triggering factors for abrasions, such as intense exercise, in order to prevent such cases. If a hematoma has developed as a result of an abrasion, it should be treated promptly at a hospital and can be relieved by hematoma incision and drainage with the help of a specialist. In case of discomfort after surgery, it is recommended to go to the hospital as soon as possible to improve imaging examinations such as X-rays and CT to avoid delaying the condition.