A 70-Year-Old Man With Severe Hand Pain, Part 1

Introduction. A 70-year-old man presented to urgent care with severe pain of the right hand.

Patient history. The pain began one day earlier on the dorsum of the patient’s right hand. The pain became severe overnight, along with marked fatigue and lassitude. The only trauma he recalled was a small scratch and puncture wound that occurred 2 to 3 days prior. The patient and his friends from his Vietnam platoon had been catching crabs in the Chesapeake Bay and placing them in baskets as part of their summer vacation/reunion. No one else in the group has contracted an illness. The patient took acetaminophen prior to his presentation for the pain, with no real effect.

The patient does not have heart disease, chronic obstructive pulmonary disease, diabetes, or hypertension. At 58 years old, he was diagnosed with Hepatitis C as part of a screening program for veterans exposed to intravenous drugs when younger. At that time, following a liver biopsy, he was diagnosed with mild cirrhosis. He received an anti-viral and has tested negative for Hepatitis C ever since. His liver functions were generally normal 1 year ago.

Physical examination. The patient’s physical examination showed a toxic appearing man in severe pain of the right hand. The patient’s pulse measured at 120 beats per minute, with a blood pressure of 100/65, and a temperature of 100ºF. The patient’s right hand had some swelling and redness centered by the presence of a small puncture wound laterally on the dorsum of the hand. There was no purulent drainage, crepitus, or bullae. Plain films and CT imaging were positive for soft tissue edema but negative for fracture or the presence of gas.

(Answer and discussion on the next page).