A 19 year-old male presents with one week of finger swelling and pain. He is a recent immigrant to NYC from the Caribbean. Seven days ago he noted that the end of his finger was swollen, painful and red. The next day he tried to lance it with a pin. He went to another ED for an evaluation. He had a normal x-ray, and was placed on cephalexin. He comes to you today because the pain is so severe that he wants the finger amputated.

No past history or surgeries

cephalexin 500mg q.i.d. No allergies

Appearance:	VS Temp 37C, HR 98, RR 16, BP 110/78. He appears uncomfortable and is holding his hand high over his head.
HEENT:	NC/AT, neck supple
Lungs:	clear bilaterally
Heart:	regular rate and rhythm, no murmurs
Abdomen:	soft and benign
Extremities:	right middle finger is severely swollen, the distal phalanx is red and exquisitely tender on the palmar side.
Neuro:	alert and cooperative.