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Clinical Question - swollen finger


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Patient: 84yo female seen in FP clinic for hospital followup 3 days after discharge.  She was admitted for acute and profound anemia (somewhere in the range of 4.5, was 9.8 the week prior).  She received two units of blood in the hospital but did well until discharge.  During clinic visit today noticed that her left index finger was significantly swollen, erythematous, partially flexed, but the hand was spared.  She states this had been present for 3 weeks and was extremely painful.

Exam: left 2nd digit significant swelling, erythema, partial flexion at rest, pain with passive extension, tender to palpation over flexor tendon.

Diagnosis: ??

I know what I diagnosed it as, and I know what I did, curious what others would do - and then I have follow up questions due to some issues with providers in another location.

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textbook tenosynovitis

any sign of puncture wound, abrasion, nail biting etc? X-rays to rule out other source although unlikely (gout, arth). Presumably it is infectious. Refer to hand specialist like now. I assume based on your post about "providers in another location" that you did do this?

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Three cardinal signs of infectious tenosynovitis:

1. Fusiform swelling (sausage finger)

2. Resting partial flexion

3. Pain with passive extension

 

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4 minutes ago, fishbum said:

From a FP clinic, shouldn't this go to the ED? Pt needs imaging, abx, and ASAP ortho consult.

It should. Guess it depends on your FP situation/location. If I saw this in our ortho clinic we have a hand doc to expedite (ie, direct admit to OR), but I work in ortho so a bit different.

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Good job all, seems majority picked up the Kanavel signs.

So now for the rest: took an XR to rule out break - obviously negative.  Called to give report on patient to ED and doc tells me not to send her and just splint and give her oral steroids...!!!!!!!  How in the world could he possibly diagnose her with anything without seeing the finger, and how could he possibly think that splint + steroids was optimal treatment for tenosynovitis?

So I tell him "tough noogies" I'm sending the patient and highly recommend an ortho consult.  He begin to cuss me out and I then find out later he called the CEO of our privately owned practice to b*#$@ about how I as a PA wouldn't listen to a "superior physician."  The CEO laughed it off, but I am asking that a report be made for the absolute inappropriate recommendation and inappropriate professional behavior from the ED doc, but also HOW WAS THIS NOT SEEN WHEN THE WOMAN WAS IN THE HOSPITAL LAST WEEK - it's been there three weeks?!?

Last bit, she's already been to surgery and will probably lose the finger...sad.

 

My question, should I stop my crusade or really push for the report to be made?

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34 minutes ago, mgriffiths said: HOW WAS THIS NOT SEEN WHEN THE WOMAN WAS IN THE HOSPITAL LAST WEEK - it's been there three weeks?!?

 

^My thoughts exactly while reading your post. 

Classic description of flexor tenosynovitis. The mnemonic I made up during didactic year to remember the Kanavel signs was "super painful flexor tenosynovitis" (original, I know). 

S = swelling/"sausage" finger 

P = pain w/ passive ROM

F = flexed finger posture 

T = tenderness along flexor tendon

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I rarely talk to an ER doc when sending a patient from clinic (and I have many years of ER experience).  I will typically give a call to the triage or charge nurse, tell them what I am sending, what my concerns are, and jot their name in the chart.  More a courtesy than anything.  

Interesting aside: had an early thirties guy come in a couple of weeks ago with some fluctuant swelling and mild erythema over just the flexor proximal phalanx.  Had been working with a hammer a few days prior, and described some friction injury on the skin.  Had none of the concerning signs or symptoms of an infectious tenosynovitis.  Did a little superficial abrasion incision with a needle bevel.  Released some serosang fluid.  Covered with an antibiotic, and very strict instructions for heading to the ER if things looked worse.  Have tried telephone follow up a few times, and he hasn't gotten back to me.

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6 hours ago, CAdamsPAC said:

What's your SP opinion on this event??Without their support you might come up short in addressing this event. Is there an office that deals with professional conduct in the hospital?

SP is on vacation at the moment, so technically I'm being supervised by one of the other docs at another clinic, but I do plan to talk with him about it next week.  There is an office of professional conduct, but would prefer the CEO also file if I'm going to just to corroborate his conversation with ED doc and support me.  Unless I push him to, the CEO isn't going to file, and I guess I'm asking if I should really push for that.

 

7 hours ago, ral said:

I rarely talk to an ER doc when sending a patient from clinic (and I have many years of ER experience).  I will typically give a call to the triage or charge nurse, tell them what I am sending, what my concerns are, and jot their name in the chart.  More a courtesy than anything.  

If I send a patient to the ED I call to give report.  Usually it's a triage or charge nurse, but every few I get one of the ED providers.  I wasn't trying to ask for the ED doc's opinion or ideas on treatment, just trying to give them a heads up when he decided to try to treat over the phone.

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mgriffiths,  You know how fast a physician would turn YOU in!!  It would singe the hair on your head.  Absolutely pursue it.  Physicians are not above the law although some specialists would disagree with me.  Luckily you have a pathway that holds all accountable.

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If the physician wants to be the superior being then he/she has superior responsibility. To review:

1. You called to give a notification. lt's a courtesy really...not asking permission

2. Physician either misdiagnosed the patient based on..nothing or doesn't know how to treat infectious tenosynovitis.

3. Physician acted inappropriate, unprofessional, and tried to direct care that was bad for the patient. Also an EMTALA violation.

4. Physician further shows his/her ass by trying to make trouble for you when he/she was clearly in the wrong.

 

So yes you should pursue it for your fellow PAs, for the staff in the ER who I promise is suffering this abuse frequently, for the organization that is being put at risk by the physicians behavior, and for the patients who are potentially being harmed by same said behavior.

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1 hour ago, mgriffiths said:

So good news, my collaborating physician heard about this from one of the other partners in the clinic and already filed a report with the review board of the hospital - while on vacation.  I just called and reported as well.

Thanks for the input everyone!

Your collaborating physician is one of a kind I'm sorry to say.  

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It isn't that rare (though it is uncommon). We have an ortho surgeon we have to deal with who is a horses ass. Every time he misbehaves when we call him to consult on a patient my SP writes it up and sends it up the food chain. Recently the orthopod was asked if he was happy here and, if he wasn't and couldn't act like it, maybe he should find a place where he is. he has already been run off staff at one facility for his behavior.

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On 3/23/2018 at 10:48 PM, Orthohand said:

Couldn't you have called the on call hand/plastics surgeon for advise? I would have sent that patient anyways, that ED doc has no power over me.

Unfortunately we don't have on-call hand/plastics.  We're pretty rural.  With the ridiculousness I expected from ED, I did go ahead and call ortho to give them a heads up when I sent the patient to ED - they appreciated it.

Ended up they have so far been able to save her finger and she is doing pretty well, so seems things are working out for the patient...which that's why we're all here!

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Wow!  Definitely agree with everyone else in reporting it.  At our ED, we as PAs take the calls for incoming patients... the incoming phone line is not the place for us to give advice and recommendations.... we are there to take report on the patient being sent our way and that's that.  What the ED doc did was uncalled for.  

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