33 year old male presents to the ED complaining of leg pain and swelling. He states he had what he thought was an insect bit on his lower leg, near his ankle. "It was a painful bump on my ankle." He tried to pop it without much coming out. Over the next couple days his ankle and lower leg became erythematous and swollen. He now complains of generalized pain of that lower extremity. Denies fever, headache, chills, nausea, or vomiting.
PMH: none
Allergies: Penicillins (rash)
Social History: non-contributory
Meds: daily vitamin
VS: HR82, RR18, BP138/70, O2 99% on RA, T 99.2
Labs:
CBC: Hb 12.5, Hct 39, WBC 12.5, Plt 200,000
CMP: Na 125, K 4, Cl 109, CO2 25, BUN 8, Cr 0.8, Glu 109
PE: Alert, oriented, and pleasant 33 y/o M in no acute distress. Normal S1S2 w/o MRG, lungs CTAB, abdomen S/NT/ND, peripheral pulses 2+ bilaterally (radial, DP, PT). R lower extremity has some distal erythema, edema, and is warm and tender to the touch. Small (<1cm) papule on R ankle without drainage. Distal sensation and ROM intact.
(His leg looks similar to this)
1. What is your differential diagnosis (list at least 3)?
2. What is your plan (include your patient disposition)?
3. What kind of patient education would you provide and what is your plan for follow up care (these are very important for your patient and your documentation)?
PMH: none
Allergies: Penicillins (rash)
Social History: non-contributory
Meds: daily vitamin
VS: HR82, RR18, BP138/70, O2 99% on RA, T 99.2
Labs:
CBC: Hb 12.5, Hct 39, WBC 12.5, Plt 200,000
CMP: Na 125, K 4, Cl 109, CO2 25, BUN 8, Cr 0.8, Glu 109
PE: Alert, oriented, and pleasant 33 y/o M in no acute distress. Normal S1S2 w/o MRG, lungs CTAB, abdomen S/NT/ND, peripheral pulses 2+ bilaterally (radial, DP, PT). R lower extremity has some distal erythema, edema, and is warm and tender to the touch. Small (<1cm) papule on R ankle without drainage. Distal sensation and ROM intact.
(His leg looks similar to this)
1. What is your differential diagnosis (list at least 3)?
2. What is your plan (include your patient disposition)?
3. What kind of patient education would you provide and what is your plan for follow up care (these are very important for your patient and your documentation)?
I'll take a stab. 1. Cellulitis, Spider bite, Gout, DVT. 2. Order CBC, CMP, Uric acid level, CRP, ESR, D-dimer, blood cultures. The first three labs are probably sufficient. I would guess it is one of the first 2 on the differential. I would give Keflex since it has good coverage for cellulitis and secondary infection if it is a spider bite that becomes necrotic. NDAIDS for pain/inflammation. Education: Take all of the antibiotics. If it is a spider bite that becomes necrotic, don't freak out. Wrap with dry gauze, keep it clean, it will heal. If it doesn't show improvement in 1 week or gets worse, come back.
ReplyDeleteChris said pretty much what I was going to. Highly likely cellulitis. Only thing I might do different is give him clindamycin tid to cover for MRSA. Education wise, spray your crib for spiders trick!
ReplyDeleteClinda would be better. I was going to wait and see, but I guess you could culture any exudate since he was getting some from the wound to be sure.
ReplyDelete