15: Skin and Soft Tissue Infection I

PATIENT PRESENTATION

Chief Complaint

“My hand hurts really bad; it feels hot, like it is on fire.”

History of Present Illness

SL is 25-year-old man who presents to the emergency department with worsening pain, redness, and swelling in his right hand. He got a splinter of wood on the palmer surface of his right hand near the base of his thumb 3 days ago while chopping wood. He thought he successfully removed the splinter, but the hand progressively became more painful and swollen where the splinter had been. Today, the burning pain (rated 8/10) has spread through his forearm and he is now feeling the pain up to his armpit. He reports that chills started yesterday. No numbness or tingling of the arm or hand, no weakness noted. Denies any prior issues with the hand.

Past Medical History

Recurrent major depressive disorder; ulnar neuropathy of left upper extremity secondary to motor vehicle accident 2 years ago; hepatitis C

Surgical History

Repair of anterior cruciate ligament in left knee in 2015; cholecystectomy in 2013; motor vehicle accident 2 years ago resulted in anterior cervical disc fusion C6/7, and repair of cervical fractures

Family History

Father has COPD; mother is healthy

Social History

Single; lives with friends; mechanic work occasionally in the past, but is currently unemployed. Smokes 1 ppd × 7 years and drinks 1 case of beer per week. Smokes marijuana, and inhales or injects methamphetamine daily.

Allergies

Penicillin (rash); sulfa (hives); morphine (itching)

Home Medications

Duloxetine 60 mg PO daily (nonadherent)

Amitriptyline 50 mg PO at bedtime (nonadherent)

Albuterol metered-dose-inhaler 1 to 2 puffs q4h PRN shortness of breath (nonadherent)

Physical Examination

Vital Signs

Temp 98.8°F, HR 80 beats per minute, RR 16 breaths per minute, BP 127/83 mm Hg, pO₂ 97% on room air; Ht 6′2″, Wt 67 kg

General

He appears thin and not well nourished. Not significantly distressed, but somewhat anxious.

HEENT

Normocephalic and atraumatic; no scleral icterus; normal range of motion; neck supple

Pulmonary

Breath sounds normal. He has no wheezes or rales.

Cardiovascular

Normal rate and regular rhythm; no murmur heard

Abdomen

Soft; no tenderness

Neurology

Alert and oriented to person, place, and time