A 33-year-old restaurant worker presented at an urgent care center with a deep hand laceration. He was triaged by a physician’s assistant (PA), sent to the surgery department, and treated by a nurse practitioner (NP). The NP irrigated, sutured, and dressed the wound. The patient was given oral instructions on wound care and the signs and symptoms of infection.
The next day, the patient called the center with complaints of extreme pain. The treating NP prescribed Tylenol with Codeine. Five hours later, the patient called the NP again stating that the pain medication had been ineffective and that he was now having chills. The NP advised him to take an anti-inflammatory agent. Later that same day, the patient called the center again reporting a fever. He was seen that evening by the PA who had done his initial triage.
The PA examined the patient’s hand and found the wound to be reddened, swollen, and hot. A lymphangitis (red streaking) was also noted which extended just distally to the antecubital fossa, indicating that the lymphatic system was also involved in the infection process. The patient was febrile (100) even after several doses of ibuprofen. The PA diagnosed abscess formation, lymphangitis, and significant cellulitis.
After consulting with the covering surgeon, the PA removed six of the nine sutures and observed spontaneous evacuation of purulent material, including old non-clotted blood. The wound was cultured, irrigated with saline and peroxide, and dressed. The lymphangitis and cellulitis were delineated.
The patient was given intravenous antibiotics and discharged home on oral dicloxacillin. A follow-up appointment was made for the next morning. He was instructed to keep the limb elevated and go to the ED if fever or chills developed. Subsequently, the CBC revealed a WBC of 17,000, and the culture was positive for streptococcal and staphylococcus organisms.
The following morning, the patient presented at the center with severe pain with passive motion of the digits and increased edema. He was admitted to the hospital where he underwent three irrigation and debridement procedures and received IV antibiotics. He was discharged home with occupational therapy and IV antibiotics. He was left with scarring and some loss of function of his left hand.