Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Evaluation for suspected clostridial myonecrosis, assessment of clinical findings, and initiation of emergent treatment.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following details of the injury:
Mechanism of injury (puncture wound, trauma, surgery)
Time since injury
Progression of symptoms:
Pain (sudden onset, severe, out of proportion to injury)
Swelling (rapidly progressive)
Erythema (redness)
Crepitus (gaseous crackling sound under the skin)
Fever
Malaise
Use of any medications (including antibiotics)
Past Medical History:
Briefly summarize relevant past medical history, including:
Underlying medical conditions (diabetes, peripheral vascular disease) that can increase susceptibility
Previous surgeries (especially recent)
History of intravenous drug use (risk factor)
Social History:
Inquire about occupational exposures to soil or contaminated environments.
Objective (O):
Vital Signs:
Record temperature (often elevated), heart rate (may be elevated), blood pressure, respiratory rate, and oxygen saturation (SpO2).
Physical Exam:
Assess for:
Localized pain and tenderness
Swelling (boggy, warm)
Erythema (redness) with a bronzed discoloration in advanced stages
Crepitus on palpation (gaseous crackling under the skin)
Blisters or skin breakdown
Signs of systemic inflammatory response syndrome (SIRS)
Consider compartment syndrome exam if swelling is tense and painful
Laboratory Tests:
Order immediate laboratory tests, including:
Complete blood count (CBC) with differential (elevated white blood cell count)
Electrolytes
Creatinine kinase (CK) levels (often markedly elevated)
Blood cultures (aerobic and anaerobic) from multiple sites (blood, tissue)
Consider additional labs as indicated:
Lactate levels (elevated)
Coagulation studies
Myoglobinuria (reddish urine)
Imaging Studies (if readily available):
Consider urgent plain X-rays to assess for gas in the soft tissues (suggestive of clostridial infection).
Ultrasound or CT scan may be helpful in some cases.
Assessment (A):
Clinical suspicion of clostridial myonecrosis:
Integrate clinical findings (rapid progression of pain, swelling, erythema, crepitus) with laboratory results (elevated white blood cell count, elevated CK) to raise suspicion for clostridial myonecrosis.
Severity of Illness:
Assess the severity of illness based on clinical presentation and systemic involvement.
Plan (P):
Emergent Treatment:
Initiate broad-spectrum intravenous antibiotics to cover potential clostridial species while awaiting culture results.
Aggressive surgical debridement of all necrotic and devitalized tissue is essential for definitive treatment. Early and repeated debridement may be necessary.
Fluid resuscitation to maintain hemodynamic stability.
Hyperbaric oxygen therapy (HBO) may be considered as adjunctive therapy.
Supportive Care:
Pain management
Nutritional support
Laboratory Monitoring:
Closely monitor laboratory tests (CBC, electrolytes, CK, lactate) to assess response to treatment.
Imaging Follow-up:
Consider serial X-rays or other imaging to monitor the extent of debridement and progression of infection.
Consultations:
Early consultation with an infectious disease specialist and a surgeon experienced in managing necrotizing soft tissue infections is crucial.
Patient Education:
Briefly explain the suspected diagnosis and the urgency of treatment.
Prognosis:
Discuss the serious nature of clostridial myonecrosis and the potential for complications (e.g., sepsis, organ failure, limb amputation).
Note: Due to the rapidly progressive nature of clostridial myonecrosis, prompt diagnosis and aggressive treatment are essential to improve outcomes. This template serves as a guide, and the specific plan may vary depending on the individual patient’s presentation and available resources.