Lower Extremity Complicated Soft Tissue Infection Consult Sample Report
DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Complicated skin and soft tissue infection of the left lower extremity.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male with borderline diabetes mellitus, hepatitis C associated cirrhosis, and end-stage liver disease who presents because of pain in his left lower extremity for several days. He believes he bumped the lateral edge of fifth digit of his left foot on something several days ago. This became painful and swollen, and subsequently, he developed increasing erythema, induration, and pain up his left lower extremity.
He states the pain is quite intense on admission and radiates directly to his groin. Since he has been in and been treated with broad-spectrum IV antimicrobials, the pain has improved, but the swelling and erythema had remained quite marked. He has had a noncontrast CAT scan of the left lower extremity, which did not reveal any abscess. He has had an MRI that included the foot and to just below the mid calf. It did not show any abscess. Blood cultures obtained on admission grew group A beta-hemolytic Streptococcus.
The patient was treated with broad-spectrum antimicrobial therapy that well covered this organism but has continued to have concerning symptoms in his left lower extremity, and over the past few days, he has had an increasing white count. He has had diarrhea over the past 24 to 48 hours but has been given lactulose because of his diagnosis of end-stage liver disease.
PAST MEDICAL HISTORY: Diabetes mellitus; hepatitis C; history of gastrointestinal bleed; migraine headaches; unspecified arthritis; morbid obesity; anemia; depression; history of difficulty sleeping and insomnia; portal gastropathy; history of Mallory-Weiss tear; history of ascites, likely associated with his hepatitis C cirrhosis; and history of esophageal varices, also associated with cirrhosis.
ALLERGIES: ASPIRIN.
SOCIAL HISTORY: The patient is disabled. He is divorced and has a 14-year-old daughter. He denies any current tobacco abuse and quit alcohol within the past year. He does have a prior history of heavy alcohol abuse, drinking 12-pack of beer per day for 12 years. There is no illicit drug use at this point, but he was a former heroin, cocaine, IV drug user. He has had not used any drugs since (XXXX).
FAMILY HISTORY: Significant for heart disease in his father; otherwise, it is noncontributory.
CURRENT MEDICATIONS: Lactulose 10 grams orally t.i.d., acetaminophen q.6 h. on a p.r.n. basis, Combivent metered-dose inhaler q.i.d., clindamycin 900 mg every 8 hours, Flexeril 10 mg twice daily, imipenem 500 mg every 6 hours, Flagyl 500 mg orally every 8 hours, OxyContin orally q.12 h., and vancomycin 1 gram IV q.12 h.
REVIEW OF SYSTEMS:
GENERAL: The patient states that his appetite is adequate. He does complain of pain, but mostly, this is in his left lower extremity and will be described in further detail later.
HEENT: The patient denies problems with vision, headache or hearing abnormalities.
CARDIAC: There are no chest pains or palpitations.
GASTROINTESTINAL: The patient is having diarrhea. He has had approximately 4 to 5 episodes from the day that we saw him. He denies any nausea or vomiting.
GENITOURINARY: He denies any problems urinating. There is no blood in his urine.
SKIN: The patient reports erythema in his left lower extremity, which will be described below.
NEUROLOGIC: The patient denies focal neurologic findings.
MUSCULOSKELETAL: The patient does continue to be able to ambulate about, although has increasing difficulty doing so secondary to pain in his left lower extremity.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 114/70, pulse 80, respiratory rate 20. He is 98% saturated on room air. Temperature is 36.8. He has been afebrile for most of his stay. His last temperature was 38 one week ago.
GENERAL: This is a morbidly obese male. He is awake, alert, and oriented. He is very pleasant.
HEENT: Oropharynx is clear.
NECK: Supple. There is no cervical, clavicular or axillary adenopathy.
CARDIAC: Regular rhythm. There is no murmur. There is no S3 or S4.
LUNGS: Auscultation is completely clear.
EXTREMITIES: Upper extremities do not reveal any suspicious track marks. He has no rashes on his upper extremities, and he has good radial pulses bilaterally. He has a very large abdominal pannus. The abdomen is soft, and it is nontender. There is no hepatosplenomegaly or splenomegaly. The pannus is pulled up, and there is no underlying erythema. There is tenderness in the inguinal area and around the areas of the femoral lymph nodes on the left, but we do not see any erythema or induration at this site. The right lower extremity is consistent with having a chronic edema. This is perhaps 1 to 2+ and is hard and woody in the right lower extremity. There is no tenderness to palpation. There is darkened pigmentation in the right lower extremity. It is difficult to palpate the dorsalis pedis pulses on the right, but we believe we can do so. The left lower extremity is quite remarkable. This is markedly swollen. There is tenderness even in the thigh, along the areas of the femoral lymph nodes; although, we do not see any erythema. There is dependent edema but not frank induration on the thigh area of the left lower extremity. Below the knee, the extremity is frankly quite remarkable. Below the knee, extending to about midpoint of the calf, there is erythema and marked swelling, which we suspect is two times the circumference of the right lower extremity. There is bullae formation. This is nonhemorrhagic in appearance. There is generalized tenderness. The patient was not complaining of pain until we began to squeeze on the extremity, however. There is no underlying obvious fluctuance or crepitus. There is obvious erythema and warmth. Just past the mid calf point, the edema is less bad, the erythema is less bad, and the warmth is less bad. The foot has edema, and it is approximately 2+ more so than the right. Compared to the proximal aspect of the calf, the distal aspect of the calf and the foot do not look that bad.
LABORATORY DATA: Sodium 134, potassium 3.6, chloride 100, CO2 of 25, BUN 12, creatinine 1.2, and glucose 86. AST 78, ALT 28, alkaline phosphatase 108. Total bilirubin 3.2, direct bilirubin 1.6. CBC shows a white count of 30,600 today, down from 37,800 yesterday. Hemoglobin 11.4, hematocrit 32.4, and platelet count 42,000, which is down from 144,000 yesterday. Stool checked for C. difficile yesterday is negative. Blood cultures from one week ago have grown group A beta hemolytic Streptococcus. Subsequent blood cultures are negative. Urinalysis from 3 days ago shows 2 to 5 white cells and 2 to 5 red cells.
DIAGNOSTIC DATA: Noncontrast CT of the left lower extremity does not reveal any abscess and does show extensive cellulitis. MRI of the left lower extremity, which essentially involves only the distal aspect of the calf and the foot, shows only extensive soft tissue swelling but no evidence of any abscess. We have reviewed these.
IMPRESSION: This is a (XX)-year-old male with a complicated skin and soft tissue infection of the left lower extremity. Complicating comorbid conditions included morbid obesity and end-stage liver disease. He also has borderline renal function. He has history of borderline diabetes mellitus, but blood sugars have been easily controlled here in the hospital. The patient has been treated with broad-spectrum antimicrobial therapy. He continues to have fairly severe cellulitis of the proximal calf of his left lower extremity. The reason may simply be that he is obese and this will take quite some time to resolve. On the other hand, at this point, we do not feel we have adequately ruled out the possibility of dead tissue deep in the leg or an abscess. Unfortunately, the test of choice at this time is an MRI because of his renal function. The MRI was only done at the distal aspect of the calf, which is now where most of the business is at this time.
PLAN:
1. Complicated skin and soft tissue infection of the left lower extremity: For now, the current antibiotics are more than adequate. We would recommend an MRI of the proximal calf. If this does not show any evidence of necrotic tissue or abscess, we can talk about changing his antimicrobial spectrum for better tissue penetration. Presumptively, the causative organism is group A beta-hemolytic Streptococcus as this was found in his blood. Thus, the current beta-lactam agent, which is comprised of imipenem along with clindamycin, should be quite adequate. We noted when we examined the patient that his leg was not elevated. Careful attention to keeping the leg elevated 90% of the time or more and possibly the use of compressive dressings should be considered.
2. Leukocytosis. He had a profound leukocytosis over the past 1 to 2 days. He has had diarrhea. Stools should be sent multiple times for C. difficile toxin assay. The patient has empirically been placed on Flagyl, and he has had an improvement in his white count. It may be that while he is having all this diarrhea, it is reasonable to hold his lactulose, so that he only has 2 to 3 soft stools per day.
