Authors: Steven E. Holt, MD
Affiliations: Brooke Army Medical Center, San Antonio
TX
Joint Military Medical Centers of San Antonio
Emergency Medicine Residency (SEH)
Photographic Critique: Michael A. Morris
University of Arkansas Medical School
Little Rock AR
Chief Complaint:
Right middle finger pain
History of present illness:
A 65 year old right-hand dominant man presents with two days of right middle finger pain and swelling after accidentally slamming his finger in a car door. Pain is localized to the dorsal fingertip. He denies fever and worsening joint pain. Function of the finger remains normal. He has a history of hypertension and rheumatoid arthritis. He had bilateral total knee replacements three years ago. His current medications include nifedipine, doxazosin, aspirin, salsalate, methotrexate, and prednisone. Immunizations are current. The rest of his review of systems is noncontributory.
Physical examination:
The patient is alert and in no acute distress. The vital signs are normal. The right hand examination reveals a 3 X 5 millimeter subungal hematoma at the nail base margin with a 5 X 7 millimeter area of surrounding pus. There is also surrounding erythema around the paronychia border (figure 1). The patient has mild tenderness to palpation over the nail. He has a 7 X 9 millimeter subcutaneous nodule near the distal interphalangeal joint. Capillary refill is less than 2 seconds. Two point sensation is intact to less than 5 millimeters. Flexor digitorum profundus and superficialis function are normal. Extensor digitorum comminus function is normal. Strength is normal. There are well healed surgical scars over the anterior aspect of both knees (figure 2). The rest of the physical exam is normal.
Laboratory:
Complete blood count is normal. Erythrocyte sedimentation rate is 23 millimeters/hour.
X-ray:
Right middle finger x-rays reveal no fractures or dislocation a with soft tissue mass on the radial aspect of the finger.
Disclaimer: The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Departments of Army and Air Force, or the Department of Defense.
Acknowledgment: Funding for these educational materials has been provided by Glaxo Pharmaceuticals through a grant to The University of Texas Health Sciences Center at San Antonio.
Funding for color reproduction of the published photographs has been provided through a grant to the publisher by Clinical Communications Inc. of Greenwich CT, a medical education and publishing company that develops educational programs for health care professionals.
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