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Smelly Foot

 

History of Present Illness:

A man in his 60’s with a history of DM and left BKA is brought to the ED by his wife for a pink smelly right foot that has been getting gradually worse for 2 weeks.  He did not want to see a doctor but the smell got so bad that his wife finally called 911.   He denies any fever, recent trauma or other complaints though he says he broke it a long time ago.

Vital Signs & Physical Exam:

Vital signs are normal except for  a pulse of 118. Physical exam is otherwise normal except for the BKA on the other leg and a stinky right foot with a large black eschar.

Initial Diagnostic Testing:

  • Labs: glucose 350, bicarb normal, lactate 2.5, creatinine 2.1, WBC 32K, 12 bands
  • Imaging: See below

QUESTIONS:

  1. What does the case image show?  
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case?  
  4. Want to know what happened with this patient?

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

 

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ANSWERS:

  1. What does the case image show?  Degenerative changes and possible old fracture, but more importantly gas in the soft tissues concerning for necrotizing fasciitis.  See second view below showing the gas bubbles more clearly, tracking all the way up into the ankle.
  2. What should you do next?  Give broad spectrum ABX and consult ortho for urgent surgery
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  See case conclusion below tutorial page.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

CLICK HERE TO LEAR MORE ABOUT THIS BOOK

CASE CONCLUSION: He was started on vancomycin, Zosyn and clindamycin.  Orthopedics was consulted and they took him emergently to the OR to perform a BKA

CASE LESSONS:

  • Always think “could this be nec-fasc” when you care for a patient with cellulitis or abscess.  Know the risk factors and red flags in the sample page above and perform imaging when indicated.
  • Beware of pitfalls such as cases that present indolently or other atypical features.
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