May 2015 Critical Care Case of the Month: An Infected Leg

Sandra L. Till DO and Robert A. Raschke MD

Banner University Good Samaritan Medical Center

Phoenix, AZ

History of Present Illness

A 46-year-old transferred due to concern for necrotizing fasciitis. One the day prior to transfer purple discoloration was not noted in the lower portion of the left leg. On the day of transfer the leg became more purple, painful, and swollen. She presented to a pain clinic that advised her to go to an emergency room. The emergency room performed arterial Doppler ultrasound, which was normal and transferred her due to concern of necrotizing fasciitis.

Past Medical History, Social History and Family History

She has a past medical history of fibromyalgia. She had an extensive surgical history including an appendectomy, bladder implant, cholecystectomy, dilatation and curettage, esophageal repair, left femoral artery repair due to a motor vehicle accident, partial hysterectomy, left knee surgery, and several left leg operations with grafting. Family history was non-contributory. The patient was single with two children, and smoked 1-2 packs of cigarettes per day for 30 years. She denied any illicit drugs or alcohol abuse.

Medications

• Zolpidem
• Warfarin
• Furosemide
• Potassium Chloride
• Morphine sulfate
• Gabapentin
• Oxycodone
• Alprazolam
• Ondansetron
• Amitriptyline

Physical Examination

Vitals signs: Blood pressure 128/85 mm Hg, pulse 86 beat/min, respiratory rate 12, temperature 36.7º C, SPO2 96% on 2L/min of oxygen.

General: Non-toxic, alert and oriented x3, tearful due to pain.

The remainder of the physical examination was unremarkable except for the left lower extremity (Figure 1).

Figure 1. Photograph of the patient's left leg.

Which of the following are appropriate at this time? (Click on the correct answer to proceed to the second of five panels)

1. Blood cultures
2. Complete blood count, c-reactive protein, sodium, creatinine and glucose
3. Surgery consult
4. Wound culture
5. All of the above

Reference as: Till SL, Raschke RA. May 2015 critical care case of the month: an infected leg. Southwest J Pulm Crit Care. 2015;10(5):208-15. doi: http://dx.doi.org/10.13175/swjpcc045-15 PDF