Moderator ventana Posted July 11, 2011 Moderator CC: my cat bit me yesterday HPI: patients own cats were fighting yesterday, she tried to break up the fight and got a bite to the left hand - didn't worry about it initially but then this morning left hand is swollen and red. What else do you want to know????
jmj11 Posted July 11, 2011 CC: my cat bit me yesterday HPI: patients own cats were fighting yesterday, she tried to break up the fight and got a bite to the left hand - didn't worry about it initially but then this morning left hand is swollen and red. What else do you want to know???? What kind of health insurance does she have . . . ha, ha. No, I will stay out of this one.
delco714 Posted July 11, 2011 Is the cats vax utd. Pt vax utd esp. Tetanus (dtap or td). Look for signs of sepsis (red line traveling up lymph tract). Likely treat with amox/clav?
Moderator ventana Posted July 11, 2011 Author Moderator Cats were both adopted with in the last twelve months from the local shelter (and they have to have rabies prior to adoption) - check Patient "I have never had a tetanus" - what to do?? ROS questions? other things you want to know? what would have you worried or anxious?
GeneValgene Posted July 11, 2011 fever, chills? would need to give tetanus prophylaxis... any x-rays of the hand taken? did the wound puncture a joint space?
chiaroscuro27 Posted July 11, 2011 fever, chills, lymphadenopathy present? Did she attempt to occlude the would with a bandaid or dressing? I'd like to know exactly where the bite is located. Is it along a joint? I'd be worried about a septic joint. Any discharge from the wound? PMH - does pt have any medical issues that put her at risk for poor wound healing?
Just Steve Posted July 11, 2011 left armpit swelling? cat scratch fever? Do you have Ted Nugent playing in your head?
Guest guthriesm Posted July 12, 2011 ROS: General: lymphadenopathy, fever, rash, Skin:- any signs of phlebitis, nail bed, pus, etc MS: any swollen joints? potential for broken bone or shredded tendon? Hx: has this happened before? PE: general survey (are they diaphoretic, pale, etc- how sick do they look?), vitals (in particular fever and bp), how swollen is the hand (do they have rings that need to be removed?). Assessment: bacterial infection; most common for animal bites is P. multicoida; Plan- treat with doxycycline 500mg bid; tetnus shot for prophylaxis Labs- not needed unless they look sick- then CBCD, bacterial cultures (x3), and possible admission for IV abx X-ray- possibly, depends on where the bite is on the hand; Education- keep the area clean and bandaged and next time let the cats figure out their own problems.
sarraeo26 Posted July 12, 2011 Has the cat bitten anyone else before? Does the pt have any other symptoms or is only the left hand affected? Is it likely the pt has a Pasteurella multocida infection? Treat pt with tetanus shot, antibiotics? (I'm just guessing for fun, I haven't started PA school yet)
Guest guthriesm Posted July 12, 2011 ah snap! guthriesm beat me to the P. multocida infxn by 4 minutes! :-) I learned that one in my previous incarnation as a lab person. I know the dosing b/c I know someone who had essentially this type of injury. Worst part- bite went through the nail and she had a rather ugly finger for several weeks.
Just Steve Posted July 12, 2011 I found it interesting that people listed a tetanus vaccine as part of the overall treatment. I was under the impression that such a bug is a soil born pathogen and typically a concern if a person receives an open when outside. It doesn't take much imagination to believe a cat could find themselves out of doors...but hypothetically speaking, if the critter was an indoor critter...would you worry about tetanus? Now I truly believe the cat to be a most filthy animal. Their bite is one of the most bacterial laden bites around. I don't know where cat litter comes from...is it a compound that contains soil that could contain the tetanus bug? (Clostridium tetani) Please don't misconstrue my post as to doubting the wisdom of the vaccine, personally, I don't see much harm in it. However, there are some weird folks out there who don't like vaccines. If your patient was really against the vaccine...would you give them the full court press and try your hardest to convince them to get it? Or simply say "ok, but I don't recommend skipping" and let it go at that? after reading a snippet on the disease, it makes me want to go get a vaccine even though I don't think I'm due http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001640/
thinkertdm Posted July 12, 2011 Don't forget to x-ray to r/o broken cat teeth in the wound. And advise the cat to see a vet, people are dirty, dirty animals.
GeneValgene Posted July 12, 2011 I found it interesting that people listed a tetanus vaccine as part of the overall treatment. I was under the impression that such a bug is a soil born pathogen and typically a concern if a person receives an open when outside. It doesn't take much imagination to believe a cat could find themselves out of doors...but hypothetically speaking, if the critter was an indoor critter...would you worry about tetanus? Now I truly believe the cat to be a most filthy animal. Their bite is one of the most bacterial laden bites around. I don't know where cat litter comes from...is it a compound that contains soil that could contain the tetanus bug? (Clostridium tetani) Please don't misconstrue my post as to doubting the wisdom of the vaccine, personally, I don't see much harm in it. However, there are some weird folks out there who don't like vaccines. If your patient was really against the vaccine...would you give them the full court press and try your hardest to convince them to get it? Or simply say "ok, but I don't recommend skipping" and let it go at that? after reading a snippet on the disease, it makes me want to go get a vaccine even though I don't think I'm due http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001640/ because the patient isn't immunized, they need to get up to date anyways. i think standard of care is to give them Tdap+TIG, and then tell them to return at the appropriate times to finish out the Td series. also, i think most people tend to give Augmentin over doxy as first line treatment... but i'm just a student, so i could be wrong about all this :)
RRivas2004 Posted July 12, 2011 Rabies more common in racoons, bats, and skunks. Leprosy in armadillos of all things... Admit for IV abx if signs of (systemic) infx. Cat bites/scratch are no joke.
Moderator ventana Posted July 12, 2011 Author Moderator HPI: John Jones is a 63-year-old male who has adopted 2 cats and they were fighting yesterday. She broke them up and in doing so got a bite to her left and over her dorsal surface on the posterior lateral edge. Thought nothing of these initially however this morning her hand is swollen erythematous and sore. no pain with movement of any hand or wrist joints. She denies any fevers or chills. ?? Td status ROS: Constitutional: No fever or chills. No fatigue/malaise. MS: left hand pain per history of present illness, no elbow pain. no axillary LAD, no lymphangitis. Neuro: No headache. Skin: left hand and wrist erythematous however no elbow lesions or lesions other places on the skin.. Allergies: Penicillin hives PE: Vital signs: afebrile 130/80 pulse 80 respirations 14 GENERAL: Well developed, well nourished and in no distress 63-year-old female HEAD: Normocephalic and atraumatic NEURO: Alert and oriented, CN III-XII grossly intact although not individually tested. Speech is clear and appropriate. CARD: Normal S1, S2 and regular no murmurs, rubs, or gallops RESP: Normal chest excursion with respiration. Breath sounds clear and equal bilaterally without wheezes, rhonchi or rales GI: soft. MUSC: MAE. Left hand: Erythema and swelling per diagram. (In essence from the PIP joints of all her fingers up to 2 inches proximal to her ulnar styloid is erythematous and swollen on the dorsal surface.) Hot to touch. No frank purulent collection. No epitrochlear lymphadenopathy, no evidence of lymphangitis. No axillary nodes. 5/5 stength at all hand/wrist and finger joints for flex/ext. There is 2 small bite marks directly overlying the second metacarpal bone in the dorsal surface . Otherwise Visible skin normal for age and race. Skin is warm and dry with good turgor. So people hit on questions well - in asking her further about Td she thinks she was vacinated about 8 years ago but unsure Treatment - Of choice is Augmentin for covering Pasturella (what makes you think this bug BESIDES a cat bite? there is a clue in the history) BUT what to take with a PCN allergy causing hives? Doxycycline is the next choice A/P: #1 cat bite: Penicillin Allergic. With her doxycycline 100 milligrams p.o. b.i.d. x10 days. I will her first dose IV through the infusion room. Erythema was outlined in marker, Christina was shown her upper extremity today and patient will return tomorrow and be evaluated by Christina again and if there is any questions we will see a provider. Elevation, doxycycline starting tomorrow p.o.q12. Any worsening and the patient should go to emergency room. Tdap updated. I did explain the gravity of the situation to the patient and got her to understand that if she gets worse she needs immediate evaluation emergency room. Few more Questions: Why did I choose IV? Why no x-ray (and it was not due to insurance jmj11 :-)? What else for paperwork needs to get done in most jurisdictions? What is appropriate follow up time? Bonus question - what are the risks to tell the patient about Doxycycline?
RRivas2004 Posted July 12, 2011 Bite directly over the 2nd metacarpal bone, possible tensosynovitis or beginning of compartment syndrome due to the swelling. IV abx needed to aggresively reduce bacterial spread and swelling. PO would take longer to build up in body due to first pass metabolism? No point tenderness on the hand for xray? Cats have sharp teeth but dont really crush their food/prey like dogs do. Dogs bites have more psi. Tell her stay out of the sun while on Doxy. PCN allergy with hives? Take benadryl not sure. Follow up in 24hrs if swelling is not coming down **Most likely deep fascial space infection, contact Hand/Plastics? if no improvement Rudy PAS-1
Guest guthriesm Posted July 12, 2011 Also- some jurisdiction require all animal bites to be reported to animal control.
Moderator ventana Posted July 13, 2011 Author Moderator Bite directly over the 2nd metacarpal bone, possible tensosynovitis or beginning of compartment syndrome due to the swelling. IV abx needed to aggresively reduce bacterial spread and swelling. PO would take longer to build up in body due to first pass metabolism? No point tenderness on the hand for xray? Cats have sharp teeth but dont really crush their food/prey like dogs do. Dogs bites have more psi. Tell her stay out of the sun while on Doxy. PCN allergy with hives? Take benadryl not sure. Follow up in 24hrs if swelling is not coming down **Most likely deep fascial space infection, contact Hand/Plastics? if no improvement Rudy PAS-1 pretty much on the money - first dose IV as it was on the hand and invovled a sig portion and did not want to wait for PO to "get into system" Cat bites get infected (at least they think so - tough to collect data when most bites don't go to ER or access care per most recent EMRAP) due to sharp teeth and deep penetration which drags bacteria in deeper Augmenting first line, Doxy for PCN allergic - then can even go to recephin if needed to gotta cover pasturella - and the clue to this bug is the RAPID infection - can start with in hours of a bite and gets bad quick (another reason for IV) right on for follow up - since I had the day off the next day I had the MA look at the hand - and I outlined in marker - patient came back in 24 hours and the same person looked at it (if any questions she would have the doc that was on look at it) Yes and Yes to plastics referal if not getting better quick Yes to sun avoidance on doxy no real focal pain with palp - my own test is to tap over a close boney protuberance (put my own finger on it - then bang my own finger hard and if the patient does not c/o pain seems very low likelyhood of boney Fx) No pain with any finger or hand or wrist movement so less likely tendon involvement Take home: Augmentin for animal bites Quick infection is Pasturella ANY evidence of infection on hands treat aggressively and quickly refer if not better 24 hour follow up (or could do even quicker if in the ER - ie 12 hour) Nice to have same person see the infection the next time MUST determine Rabies status of animal - typically bit report form to local animal control and they will get it traked down - if unknow animal talk to DPH on rabies IVIG and Vaccine did I miss anything?? why don't we give doxy to kids???
Administrator rev ronin Posted July 13, 2011 Administrator ...but hypothetically speaking, if the critter was an indoor critter...would you worry about tetanus? Yes: 1) It's standard-of-care. Either they get the shot or they get a signed and witnessed refusal as C-my-A. 2) It's good prevention. 5 years if seen for injury, 10 years in any case, and then they don't have to worry about it. 3) It's not that expensive for the patient, compared to the risk (the ground has no herd immunity) 4) But it IS something we can bill for. If we can't keep the doors open, we can't see patients. 5) and it is what I would want someone to do for ME if I were ignorant and bit like this hypothetical patient had been.
Administrator rev ronin Posted July 13, 2011 Administrator why don't we give doxy to kids??? Because orange teeth are cool for Halloween, but not the other 364 days of the year?
Moderator ventana Posted July 13, 2011 Author Moderator Because orange teeth are cool for Halloween, but not the other 364 days of the year? Nice!!! Patient came back in yesterday and looked far better - will finish 1-2 weeks of PO abx all done........
bradtPA Posted July 13, 2011 I first assisted in the OR with a debridement of one of these cat bites. We actually irrigated the wound with IV antibiotics during the procedure....
Moderator ventana Posted July 13, 2011 Author Moderator I first assisted in the OR with a debridement of one of these cat bites. We actually irrigated the wound with IV antibiotics during the procedure.... I have used the same irrigant "bug juice" in the ER to irrigate nasty wounds - bacitracin in normal saline I want to say - I always just call the pharmacy and say I want 1L of the stuff ortho uses for irrigation....
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