17: Necrotizing Fasciitis

PATIENT PRESENTATION

Chief Complaint

“My right leg hurts.”

History of Present Illness

WL is a 52-year-old Caucasian male who presents to the emergency department with pain and redness of his lower right leg as well as fever and malaise. He also noticed bulla formation on his right shin which worsened within hours. He recalls accidentally bumping his leg on the side of his bed and sustaining an abrasion to his shin 2 days ago. He states he had to skip work the next day since it was so painful. When the pain got worse overnight, he decided to come into the emergency department.

Past Medical History

HTN, type 2 DM, HLD

Surgical History

Appendectomy

Family History

Father had CAD and passed away from a myocardial infarction at age 50; mother has type 2 DM and hypothyroidism.

Social History

Married and living with his wife. Smokes ½ ppd × 30 years and drinks alcohol socially.

Allergies

NKDA

Home Medications

Lisinopril 40 mg PO daily

Atorvastatin 80 mg PO daily

Metformin 1 g PO BID

Empagliflozin 25 mg PO daily

Physical Examination

Vital Signs

Temp 102.4°F, P 107, RR 24 breaths per minute, BP 124/70 mm Hg, pO₂ 97 %, Ht 5′11″, Wt 100 kg

General

Well-developed, well-nourished male; appears lethargic and in distress

HEENT

Normocephalic, atraumatic, PERRLA, EOMI, normal funduscopic exam, normal visual fields

Pulmonary

Clear to auscultation bilaterally, no rales/rhonchi/wheezes

Cardiovascular

NSR, no m/r/g

Abdomen

Soft, non-distended, non-tender, normal bowel sounds

Genitourinary

Deferred; no complaints of dysuria or hematuria

Neurology

Lethargic, oriented to place, person, and time

Extremities

5 × 12 cm erythematous patch with bullae on the front RLE, tender to palpation

Laboratory Findings