PMH: Negative. Her shots are up to date.

Meds: None, Allergies: None

SH: Negative

FH: Negative

ROS: No fevers, no nausea or vomiting. There is minimal redness around the bite area. No other injuries. She does note increased pain with any movement. No weakness.

PE: BP: 140/70, RR=20, Temp=98F, P=100

Thin, Well Developed, Well Nourished (WDWN) female, grimacing in pain, diaphoretic. She is holding her arm elevated.

HEENT: Unremarkable

Heart: RRR, tachy, no murmurs

Lungs: Clear

ABD: Unremarkable

Ext: Normal except right wrist. She has two puncture bites in the middle of the palmar side of the wrist. The area is exquisitely tender. There is some swelling, and minimal erythema around the bite marks. There are also two puncture wounds on the dorsal side, but these are not tender.

Motor function is difficult, as she cannot give good effort because of the pain. She does have some function of all tendons, but strength testing is not possible. She does complain of pain over the palmar surface starting at the creases in the wrist including the thumb and next two fingers. She has a little bit of pain on the dorsal side of the second and third fingers at the last phalange. She describes the pain a severe burning type of pain and is requesting cool compresses for her hand. She has decreased sensation in the area she is feeling the severe burning, but can feel sharp and dull differences.

1. What distribution of pain is this?

2. Should you order an X-ray? What are you looking for?

3. What are the risk factors for wound infection in cat bites? What is the usual organism?

4.  Her WBC ct is 10K (normal), X-ray is negative, but after 4 mg of Hydromorphone (Dilaudid), she is still in severe pain. Repeat exam reveals sensation decreased in the distribution of her pain. What do you do now?
 

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