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Question: ID

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You are seeing a 17 year old girl that works in a pet store, where she is sometimes scratched by the animals there. She felt fine that morning, but noted malaise and low-grade fever in the afternoon, and pain in her lower right shin. She presents to the ED with temp 38.5, HR 140, RR 20, BP 95/60. She has a 4cm x 4cm non-well demarcated area of red-purple discoloration on her lower right shin, with mild edema. On close inspection there are a few small bullae in the area of discoloration. On palpation of the area, it is warm, extremely, tender, and has crepitus. 

As you obtain vascular access and give broad spectrum IV antibiotics, what else should you be doing?

pemsou5_wp • June 7, 2023

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  1. Kelly June 7, 2023 - 11:41 am Reply

    E) Obtaining emergent Surgeon consultation
    The patient has signs and symptoms consistent with necrotizing fasciitis, which is a surgical emergency. Necrotizing fasciitis is a rapidly spreading deep soft tissue infection. The infection is typically polymicrobial, and broad-spectrum antibiotics should be started (e.g. a carbapenem or piperacillin-tazobactam + an agent that covers MRSA + clindaymicin for its antitoxin effects). Consultation with a surgeon should not be delayed for imaging or other work-up; patients require surgical emergent exploration and debridement. Other signs to look for include “skip lesions,” affected areas with unaffected or less affected skin between, and insensate skin (from nerve destruction).

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