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Fayetteville Technical Community College *
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244
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Medicine
Date
Apr 3, 2024
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docx
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Jasmine Baker Case Report 5 Quali- Care Clinic Report Quali-Care Clinic Report 5: Consultation (Plastic Surgery)
Patient Name
: Roy Mitchell
Patient ID
: M-14
Age
: 9
Sex
: M
Consultant
: Mark Swafford, MD, Plastics & Reconstruction Surgery5
Requesting Physician
: Antonia Connerly, MD
Date of Consult
: 05/11/----
Reason for Consultation
: Patient presents at 1400 hours today for evaluation of dog bites of bilateral upper extremities. He is accompanied by his mother.
HISTORY OF PRESENT ILLNESS: Roy is a 9-year-old white male, who was bitten by a bull mastiff on the left hand, and right forearm and hand on
5/10. He was initially seen in Hillcrest Emergency Department, evaluated by the emergency medicine physicians as well as an orthopedic surgeon. Patient was found to have significant bites, one on the volar ulnar aspect of his mid-forearm of the right upper extremity, and another puncture type wound with some erythema, induration, and edema on the Thenar eminence volar of his left hand. The patient received one
dose of intravenous Zosyn while in the ED and was discharged at 5 o’clock
on 5/10. Orthopedics in the ED had intended on getting him on oral Augmentin, however it was inadvertently prescribed at the outpatient clinic, which was closed at the time of the patient’s discharge. The mother went back to the helpdesk and was told to just pick up her son’s antibiotics when she had the follow-up visit at 10 a.m. the next day. The patient followed up with orthopedics at 1000 hours on 5/11 and was found to be not signifi cantly improved. He was subsequently referred for hospital admission if deemed necessary by our service P&RC. The patient has had no fevers and has been doing reasonably well at home with no significant change with his overall pain status. The background on the dog was that it was a stray male dog that had been taken from an animal shelter as the patient’s mother is doing rescue work with these types of animals. The child had been playing in the backyard with the animal, unsupervised apparently in somewhat of playful but not exactly provoked manner, the dog bit the child on the right wrist, forearm and left hand as previously described. The dog has since been euthanized and decapitated for cranial analysis for rabies. All appropriate forms have been filled out be the shelter for once the dog came and also from the hospital ED.
Medications: None. Previous antibiotics received include Zosyn IV in the ED.
PAST SURGICAL HISTORY: Pressure equalization tubes x2, AVM in the
antecubital fossa in the right upper arm, which was corrected surgically. Left Tympanoplasty. Right neck biopsy of benign tissue.
SOCIAL HISTORY: Patient lives at home with his mother who is a widow, no siblings.
PHYSICAL EXAMINATION: Weight is 30.5 kg. Vital Signs: Stable. No fever noted. Exam of the patient’s upper extremities reveals full strenghth with strength 5 out of 5 in bilateral deltoids, biceps, triceps, Brachioradialis, wrist, flexors, wrist extensors, finger flexors,
finger extensors, and interossei. Overall, light touch sensation is intact in both along the medium ulnar and radial dermal distribution.
Distal neurologic status shows a 5 out of 5 strength in and along the anterior interosseous and posterior interosseous as well as ulnar nerve distribution. Capillary refill is less than two seconds in all fingers, radial pulses easily palpated and is 2+ in nature bilaterally.
Specific attention to the skin findings shows multiple very small and shallow puncture/abrasions on the volar and dorsal aspects of the forearm of the right upper extremities and also on the palm and dorsum of the left hand. No fluid is expressible from the sites. The only ones that have mild erythema associated with them include one
on the volar ulnar aspect of the mid hand, which has a fair amount of erythema. No induration and no fluctuance are noted. The Thenar eminence is soft, and the patient tolerates palpation of the area
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without diffcuilt. Passive finger extenision and flexion is unimpeded and pain-free. No fluid or pus is expressed from any of these lesions.
LAB and X-RAY DATA: Patients WBC is 8.3, ESER is 14, CRP is 0.8.
LAB and X-RAY: Studies on 10 May a right forearm and left hand with
no foreign objects. No fractures noted. There is subcutaneous air noted along the volar aspect of the radius in the right forearm. The left hand shows some soft tissue swelling over the Thenar eminence but no fractures, no foreign objects, or subcutaneous emphysema. X-
rays done 11 May of the right forearm and hand. The left hand shows no interval changes, still with some subcaneous air in the Volaris, back to the distal radius on the right. FOREARM SERIES: No dislocations, fracture and no foreign objects noted. Bilateral hands and forearms showed no significant degree of soft tissue swelling at this time. ASSESMENT: This is a 9-year-old white male with bilateral hand and forearm dog bites, with cellulitis over the left Thenar eminence, and over the volar ulnar mid-forearm of the right hand without evidence of abscess at this time. PLAN: I planned to have the patient admitted overnight to the Hillcrest Medical Center pediatric service, for IV antibiotics for the next 12 to 24 hours. I plan to have the patient start Zosyn 2.4 g, IV, q.8.h, which is 80 mg per kg per 8 hours. Patient will take Tylenol for
pain control, will follow closely in the morning with laboratory evaluation as well as repeat examination of his wounds.
Patient will be NPO past midnight tonight, however, he can eat dinner this evening. I plan to place the patient in a small pancake volar splint for the left hand, for soft tissue rest, and re-evaluate in the morning as previously described. Mark Swafford, MD, Plastic & Reconstructive Surgery