Sounds just like on of our last cases of necrotising fasciitis. Red flags
here are: Alcoholic (? immunosuppressed), no relief from painkillers, an
ambulance at 4 am (in someone who has already sought out primary care (=
"please doc I have something rotten going on under my skin and I can't bare
it any longer but I am a cortically atrophied alcoholic from Brighton so I
just can't express myself properly"). Is he a regular attender ? If not
another red flag.
Need to be careful that he does'nt get treated as celluilits if it is Nec
Fasc, and an early biopsy might be very revealing. Wonder if a plain x-ray
shows any air.
But gee, you guys have to make up your minds on whether or not to admit this
chap to hospital by 8 am, don't evnvy you on that one. Happier to take a
little longer observing and getting to the bottom (sic) of it all, like
talking with GP when he pitches up in ? 5 hours time about what the leg was
like when he saw it. I hope the SHO has'nt discharged him by the time you
get in at 8 am Rowley because of 4 hour target. Then again you might have
seen him limping back down towards Kemptown and stopped to offer him a lift
back the ED on your way in. That way you would have until just after midday
to sort him out.
John
----- Original Message -----
From: "Rowley Cottingham" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Saturday, May 27, 2006 11:18 PM
Subject: A sore leg
> Male aged 38 comes in by ambulance at 4am. He has a painful left thigh.
>
> He is an alcoholic, and went shopping about 3 days ago to get food and
> drink. He thinks he banged his leg during the trip, and it is still
> sore. He has come into the ED as the painkillers his GP prescribed 2
> days ago haven't helped.
>
> The ambulance sheet is rich with exclamation marks for calling them at
> this hour. Their observations are pulse 75bpm, systolic >89mmHg, sats on
> air 98% and coma scale 15.
>
> He has no other medical history of consequence. He has no recent history
> of travel and has no respiratory symptoms.
>
> Review in the department shows a man with stable vitals; pulse 74bpm,
> temp 35 degC and walking with a little difficulty. General examination
> is unremarkable; clear chest, normal heart sounds. His leg is tender to
> touch on the medial aspect of the thigh and reddened; it feels
> locally hard to the touch. The leg is intact neurovascularly.
>
> How would you manage this patient?
>
>
> /Rowley./
>
>
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