Author: Travis Hyatt, DO
Co Author #1: Irvin Sulapas, MD
Senior Editor: Justin Mark Young, MD, FAMSSM
Editor: Justin Chu, MD

Patient Presentation:
A 39 year old male with type 1 diabetes mellitus was transferred to the hospital from an outpatient clinic for right hand swelling and foul smelling drainage. He reported that he was at boxing practice about one week prior and his hand accidentally struck the teeth of his sparring partner. They were performing a non-contact drill, and he was not wearing anything over his hands at the time. He was seen at a different emergency department shortly after the injury occurred where he had two stitches placed to loosely approximate the laceration and was discharged with amoxicillin/clavulanate. He did not take the antibiotics due to being unable to afford them.

History:
Type 1 Diabetes Mellitus

Physical Exam:
General: No apparent distress, resting comfortably in bed <br>Eyes: Extra-ocular movements intact, pupils equal and round <br>HEENT: Normocephalic, atraumatic, moist mucous membranes, no lymphadenopathy or masses <br>Cardiovascular: Regular rate and rhythm without murmur, rub or gallop. Equal 2 plus pulses in all four extremities, no peripheral edema. <br>Respiratory: lungs clear to auscultation bilaterally without crackles, rales, rhonchi, wheezes <br>Abdomen: normoactive bowel sounds, no tenderness or guarding <br>Extremities: Right upper extremity exam included in detail below. All other extremities were neurovascularly intact without injury or limitations in movement/range of motion. <br>Skin: Aside from right hand injury, skin is intact without rash or lesions elsewhere. <br>Neuro: Alert and oriented x3, cranial nerves II-XII grossly intact <br> <br>Detailed right upper extremity exam <a href="CaseStudyImages/CS1Countingto9AnUnex-1396.jpg" title="Case Photo #1" data-lity><b>Case Photo #1</b></a> <a href="CaseStudyImages/CS2CS1Countingto9AnU-1396.jpg" title="Case Photo #2" data-lity><b>Case Photo #2</b></a> : <br>Inspection: <br>- Focal erythema and swelling present along the radial side of the dorsum of his hand. Induration around the laceration and erythema diffusely about the hand. Active drainage coming from laceration site <br>- tenderness to palpation and range of 2nd finger <br>- range of motion limited by pain <br> <br>Motor: <br>Thumb: Active flexion/extension intact at metacarpophalangeal and interphalangeal joints <br>2nd finger: flexion/extension intact but range of motion reduced secondary to pain at metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints <br>3rd finger: Active flexion/extension intact at metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints <br>4th finger: Active flexion/extension at metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints <br>5th finger: Active flexion/extension intact at metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints <br> <br>Sensory: <br>Sensation intact but decreased in radial and median nerve distributions. <br> <br>Vascular: <br>2 plus radial pulse intact. Capillary refill less than 2 seconds throughout all 5 fingers.

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