Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New onset of rapidly progressing skin pain, swelling, and erythema (redness)
(Specify) Necrotizing fasciitis is a rapidly progressive and life-threatening infection. Early recognition and prompt treatment are crucial.
History of Present Illness:
Onset, location, and character of skin pain (sudden, severe, burning, out of proportion to findings).
Progression of swelling and erythema (hours to days).
Recent history of surgery, trauma (including minor breaks in the skin), insect bites, or skin infections.
Fever, chills, or other systemic symptoms.
Past Medical History:
Underlying medical conditions that may increase susceptibility to infection (e.g., diabetes, immunodeficiency, peripheral vascular disease).
Prior history of skin infections or surgeries.
Social History:
Intravenous drug use (increases risk of infection).
Recent travel (potential exposure to specific bacteria).
Physical Exam:
Vital signs: Assess for fever, tachycardia (rapid heart rate), hypotension (low blood pressure) – suggestive of sepsis.
Skin examination:
Localized area of skin pain, erythema, swelling, and induration (firmness) that is tender to palpation and may be warm.
Blisters or skin necrosis (tissue death) may be present in later stages.
Crepitus (gaseous crackling sound) under the skin may be a sign of gas production by bacteria.
Other examinations: Assess for signs of systemic infection (e.g., abdominal exam for possible source of infection).
Laboratory Tests:
Complete blood count (CBC): May show elevated white blood cells (leukocytosis)
indicative of infection.
Blood cultures: To identify the specific bacteria causing the infection.
Electrolytes: May be deranged due to dehydration or sepsis.
Serum lactate level: Elevated lactate levels can be a marker of tissue hypoxia (lack of oxygen) and severity of infection.
Imaging Studies:
Soft tissue ultrasound: May be used initially to assess for fluid collections and identify the depth of tissue involvement.
MRI scan: May provide more detailed information about the extent of fascial involvement and guide surgical debridement.
CT scan (less preferred due to radiation exposure): May be used if MRI is contraindicated.
Assessment:
Necrotizing fasciitis (suspected or confirmed): Based on clinical presentation (rapid progression of pain, swelling, erythema) and supportive findings on physical exam and imaging studies.
Severity of infection: Classified based on clinical features and laboratory findings (e.g., presence of systemic inflammatory response syndrome – SIRS, sepsis).
Possible source of infection (if identified).
Differential Diagnoses:
Consider other conditions that can cause skin pain and swelling, especially early in the disease course:
Cellulitis (bacterial skin infection)
Erysipelas (superficial skin infection)
Abscess (localized collection of pus)
Deep vein thrombosis (DVT) with skin inflammation
Plan:
Prompt surgical debridement: Removal of all necrotic and infected tissue is the cornerstone of treatment. Multiple surgeries may be necessary.
Broad-spectrum intravenous antibiotics: Initiated empirically to cover a wide range of bacteria while awaiting culture results. Antibiotics may need to be tailored based on culture sensitivities.
Supportive care: Aggressive fluid resuscitation, pain management, and monitoring for complications (e.g., sepsis, organ failure).
Hyperbaric oxygen therapy (may be considered in some cases): Increases oxygen delivery to tissues to promote healing and fight infection.
Consultations: Infectious disease specialist, plastic surgeon, and other specialties as needed.
Prognosis:
Necrotizing fasciitis is a life-threatening infection with significant morbidity and mortality. Early diagnosis and prompt treatment are crucial for improving outcomes.
Follow-up:
Close monitoring in the intensive care unit (ICU) is essential.