Everybody's input please

[Rickycen35]

I've been a nurse for 18 years, ER, CCU, PACU, and now surgery. What I want to do, is post a brief I suppose case study. I want the current and past ER nurses thoughts, and disposition on.

20 year old female, bit on her right wrist by her own indoor cat. (Cat utd on shots, etc), approximately 6 weeks ago. Two days ago this pt had complaints of itchy lesions on her right arm. Some are oozing slightly. She also complains of right arm pain, going up into her neck and jaw, with a sore throat with painfully swallowing. Her right neck and jaw feel slightly swollen, with a swollen lymphnode below her right ear. There has been no fever, although the patient has never checked her temp.

She called her doctor about 48 hrs ago, and he prescribed Cephalexin.

Today (48-72hrs after starting the antibiotic) she is crying with a painful throat.

The ER doc sees her, orders IVF's, labs, a throat culture, and a culture of a lesion on her arm.

The patient received Torodol 30mg IVP with the IVF's, which eventually relieved the pain to a "1"

On exam the patient had a swollen pharynx, with some ***** exudate. She is a febrile.

The WBC and diff came back WNL, the H&H and diff slightly low, indicating iron deficiency anemia. Strept culture negative, mono spot negative.

What's the projected plan of care and disposition with this patient?????

[Anna Flaxis, BSN, RN]

CT head and neck.

[Dragonnurse1, ASN, RN]

My first reaction was Cat Scratch Fever. Swollen glands after a scratch/bite can an indicator. The quick cultures were negative but this is a bacterial infection. Cultures were taken of the arm lesions but it would have been nice to have been able to do blood cultures however she has been on antibiotics for 2+ days. While cat scratch fever generally resolves by itself over time some people do develop complications. Parinaud's oculoglandular syndrome is one potential one(think pink eye with swollen lymph glands on the side bitten or scratched).

It is possible that there is more than one problem here. What are her allergies? Has she taken Cephalexin before? She may be intolerant of the drug, it can cause a severe sore throat among other reactions. Change medication, add an anti-inflamatory and followup when cultures are back. A followup appointment with her doctor is necessary, within 24 hours.