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Smelly Foot

UnFiNiShEd CaSe CoMe BaCk LaTeR

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History of Present Illness:

A 62-year-old male with a history of DM and left BKA is brought to the ED for a pink smelly right foot.   He denies or other complaints.  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 a stinky foot with a large black eschar.  The room stinks.

Initial Differential Diagnosis:

  • Syphilis, the great imitator

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?

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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

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CASE CONCLUSION: Had an emergent BKA amputations

CASE LESSONS:

  1. Always
  2. Never
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