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Alright, this one's pretty run of the mill. but I do have a few questions, so I figured I'd post them and see what you guys and gals think.
(Note: I included a lot in this case because I'm honestly not sure what's important and what's not.... I'm hoping you guys/gals will impart some wisdom upon me)
30 yo male hospital pharmacist presents in the morning c/o L heel pain/infection. Pt states he was seen in ED for heel pain/bleeding/redness secondary to severely fissured L heel callus 2 days prior (same hospital where pt is employed). Came to ED 2 days ago because while working pain became severe enough that he couldn't stand (pharmacist do a lot of that). Initially seen in fast-track and dx'ed w/cellulitis and started on keflex 500mg qid. Over past 2 days pain has worsened significantly and pt reports a 1 inch flucuant mass developed which was oozing bloody, ***** discharge from heel fissure. Last night (12 hours ago) pain became "unbearable" and pt lanced mass with a razor blade. reports that a large amount of *****/bloody discharge was evacuated, initially "squirting out" (yes, i wrote ***** on purpose... just for fun). Significantly pain relief achieved with lancing. Pt cleaned wound with H202 until it "stopped bubbling," covered with triple abx cream, and bandaged.
Pt presents this AM because pain is again severe, though not as bad as it was last night. Also, Wound/area surrounding wound has become more "inflammed looking." Pt is concerned because hospital has a high rate of MRSA/VRSA and mother recently recovered (3wks ago) from MRSA infection and he spent a significant amount of time with her during her illness. Pain when weight is off of the foot is "throbbing" and 5-6/10. Pain when weight is on foot is "sharp/stabbing" and 8/10.
Pt's medical Hx is significant for morbid obesity (350lbs), NIDDM, and HTN. Current meds: diovan, metformin, byetta, and claritin-D + (acutely) Keflex 500mg qid x 7 days and ibuprofen 800mg tid.
ROS negative for any systemic signs of illness.
On exam L heel is calloused with severe fissuring , many of which extend through the epidermis and are express a small amount of blood when squeezed. Erythema extends in a ciruclar pattern from insertion of achilles tendon to first 1/3rd of the arch and is moderately warm to touch. 1.5" circular lesion directly on heel of foot displays more severe erythema (deeper red, warmer to touch) as well as 1/4" incision. 4x4 placed by pt at home 2 hours prior is soaked through with purlent drainage in area under lesion, but is not "dripping." slight induration appriciated around lesion (less than I expected, actually), and small amount of flucuant material remains in wound (new or old???).
Rest of exam is normal displaying no signs of systemic illness (NL temp/HR/pressures/etc) with normal HEENT, CV, Pulmonary, and lymph exam (no lymphedemapathy appriciated in poplitial/inguinal nodes).
OK... so now the questions.
-How big of a risk factor is it that this pt has recently been around a family member with MRSA and is reguarly in hospital with high rates of MRSA?
-Given the pt's weight/NIDDM (and likely decreased circulation/etc) how much more aggressive should his treatment be than the same case involving a 30yo w/o a significant medical history?
-Given the patients HPI, past medical history, and past exposure history, would you prophylactically start this patient on a second antibiotic to cover for MRSA while awaiting cultures? What would your choice of meds be (assuming you didn't have access to the hospital resistance/sensitivity reports)? Personally, I lean pretty heavily towards adding the second antibiotic. I'd probably go for Clindamycin.... Would anyone go with Doxy/Minocycline instead? Why?
-The severe fissuring alarms me as a potential portal of entry for the bacteria. Should it? How much? Other than aggressive antimicrobial therapy how should this be addressed? Would having the patient "scrub" the area sterile a few times a day be advisable? What about liberal application of topical antimicrobial gel?
-How is standing/walking going to affect the healing of this wound? My feeling is that aside from being painful, spending 8 hours a day on the heel is probably going to slow down healing of this wound a significant amount. Should the patient be off of his feet (IE off of work) for the next few days?
-Pain control. I do think this thing hurts and don't have an issue with giving this guy a script for some narcotics. He didn't come in asking for them; he's more concerned with the possibility of MRSA. However, I've never really seen anything quite like this before and don't have a good feel for how much it would take to control the pain or if/how much doseages might need to be adjusted for such a big guy. I know that the pain from abscesses is generally treated pretty aggressively; I don't know how much more aggressive you need to be when someone has to walk on their abscess. If pressed to decide I'd probably give him 60mg of toradol and two 5mg percocet in the ED. Then send him home with a script for like 25 lortab 7.5/500 sig 1-2 q4-6hrs and instructions to keep on the ibuprofen. Reasonable? Too little/Too much?
-Unrelated specifically to this case - Do you guys/gals use PO narcotics in the ED? I've seen some places that very rarely do, but here we seem to do it fairly often instead of going IM/subQ.
Alright, thanks for humoring me. Looking forward to your answers.
Dave
(Note: I included a lot in this case because I'm honestly not sure what's important and what's not.... I'm hoping you guys/gals will impart some wisdom upon me)
30 yo male hospital pharmacist presents in the morning c/o L heel pain/infection. Pt states he was seen in ED for heel pain/bleeding/redness secondary to severely fissured L heel callus 2 days prior (same hospital where pt is employed). Came to ED 2 days ago because while working pain became severe enough that he couldn't stand (pharmacist do a lot of that). Initially seen in fast-track and dx'ed w/cellulitis and started on keflex 500mg qid. Over past 2 days pain has worsened significantly and pt reports a 1 inch flucuant mass developed which was oozing bloody, ***** discharge from heel fissure. Last night (12 hours ago) pain became "unbearable" and pt lanced mass with a razor blade. reports that a large amount of *****/bloody discharge was evacuated, initially "squirting out" (yes, i wrote ***** on purpose... just for fun). Significantly pain relief achieved with lancing. Pt cleaned wound with H202 until it "stopped bubbling," covered with triple abx cream, and bandaged.
Pt presents this AM because pain is again severe, though not as bad as it was last night. Also, Wound/area surrounding wound has become more "inflammed looking." Pt is concerned because hospital has a high rate of MRSA/VRSA and mother recently recovered (3wks ago) from MRSA infection and he spent a significant amount of time with her during her illness. Pain when weight is off of the foot is "throbbing" and 5-6/10. Pain when weight is on foot is "sharp/stabbing" and 8/10.
Pt's medical Hx is significant for morbid obesity (350lbs), NIDDM, and HTN. Current meds: diovan, metformin, byetta, and claritin-D + (acutely) Keflex 500mg qid x 7 days and ibuprofen 800mg tid.
ROS negative for any systemic signs of illness.
On exam L heel is calloused with severe fissuring , many of which extend through the epidermis and are express a small amount of blood when squeezed. Erythema extends in a ciruclar pattern from insertion of achilles tendon to first 1/3rd of the arch and is moderately warm to touch. 1.5" circular lesion directly on heel of foot displays more severe erythema (deeper red, warmer to touch) as well as 1/4" incision. 4x4 placed by pt at home 2 hours prior is soaked through with purlent drainage in area under lesion, but is not "dripping." slight induration appriciated around lesion (less than I expected, actually), and small amount of flucuant material remains in wound (new or old???).
Rest of exam is normal displaying no signs of systemic illness (NL temp/HR/pressures/etc) with normal HEENT, CV, Pulmonary, and lymph exam (no lymphedemapathy appriciated in poplitial/inguinal nodes).
OK... so now the questions.
-How big of a risk factor is it that this pt has recently been around a family member with MRSA and is reguarly in hospital with high rates of MRSA?
-Given the pt's weight/NIDDM (and likely decreased circulation/etc) how much more aggressive should his treatment be than the same case involving a 30yo w/o a significant medical history?
-Given the patients HPI, past medical history, and past exposure history, would you prophylactically start this patient on a second antibiotic to cover for MRSA while awaiting cultures? What would your choice of meds be (assuming you didn't have access to the hospital resistance/sensitivity reports)? Personally, I lean pretty heavily towards adding the second antibiotic. I'd probably go for Clindamycin.... Would anyone go with Doxy/Minocycline instead? Why?
-The severe fissuring alarms me as a potential portal of entry for the bacteria. Should it? How much? Other than aggressive antimicrobial therapy how should this be addressed? Would having the patient "scrub" the area sterile a few times a day be advisable? What about liberal application of topical antimicrobial gel?
-How is standing/walking going to affect the healing of this wound? My feeling is that aside from being painful, spending 8 hours a day on the heel is probably going to slow down healing of this wound a significant amount. Should the patient be off of his feet (IE off of work) for the next few days?
-Pain control. I do think this thing hurts and don't have an issue with giving this guy a script for some narcotics. He didn't come in asking for them; he's more concerned with the possibility of MRSA. However, I've never really seen anything quite like this before and don't have a good feel for how much it would take to control the pain or if/how much doseages might need to be adjusted for such a big guy. I know that the pain from abscesses is generally treated pretty aggressively; I don't know how much more aggressive you need to be when someone has to walk on their abscess. If pressed to decide I'd probably give him 60mg of toradol and two 5mg percocet in the ED. Then send him home with a script for like 25 lortab 7.5/500 sig 1-2 q4-6hrs and instructions to keep on the ibuprofen. Reasonable? Too little/Too much?
-Unrelated specifically to this case - Do you guys/gals use PO narcotics in the ED? I've seen some places that very rarely do, but here we seem to do it fairly often instead of going IM/subQ.
Alright, thanks for humoring me. Looking forward to your answers.
Dave
