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Dealing with isolation and medical uncertainty
Published in Peter Davies, Lindsay Moran, Hussain Gandhi, Adrian Roebuck, Clare J Taylor, The New GP′s Handbook, 2022
I suspect that for many younger GPs the conditions that cause them most problems are those that are not serious but which are miserable morbidity, and which lead to repeated visits to the surgery. For example, what exactly is a good treatment of plantar fasciitis? Were you asleep in that bit of the medical course? Have you read that bit of the textbook? Having seen a case, will you now turn it into a doctor’s educational need and look the condition up? There are lots of these minor but annoying conditions that you will rarely see in hospitals and which you will not see very often in practice. However, over time you will see most of them a few times, and you will become like a classic general physician who has seen or read about a case of every disease.
Postpartum Care
Published in Vincenzo Berghella, Obstetric Evidence Based Guidelines, 2022
Elena R. Magro-Malosso, Sarah K. Dotters-Katz, Daniele Di Mascio
Characteristic signs of wound infection are erythema, edema, heat, discharge, and induration of the incision; fever and leukocytosis may be systemic evidence of this condition. Hematoma and seroma present as a collection of blood and serum, respectively, both of which can cause dehiscence and act as a nidus for the development of wound infection [98]. Necrotizing fasciitis is a rare but serious infection of the deep soft tissue that results in progressive destruction of the muscle fascia and overlying subcutaneous fat. Severe pain, wooden-hard induration of the subcutaneous tissues, bullous lesions, skin necrosis or ecchymosis, and elevated serum creatine kinase level are usually observed [99]. Computed tomography or magnetic resonance imaging may help in the diagnosis of necrotizing fasciitis, which will be confirmed at the time of repeat surgery.
Fasciitis
Published in Maher Kurdi, Neuromuscular Pathology Made Easy, 2021
Fasciitis is an acute inflammatory disease of the fascia, either due to immune-mediated reaction or acquired by intramuscular vaccinations. The inflammation is localized to the fascia and rarely infiltrates into the muscle fibers. However, perimysial inflammation is always present and associated with lymphohistiocytic infiltrates. Careful clinical history and laboratory investigations may help the clinician to reach the diagnosis. Muscle biopsy in these cases is performed to rule out any abnormal myopathic or neuropathic conditions.
Fatal abrin poisoning by injection
Published in Clinical Toxicology, 2021
Ginger R. Rinner, Sarah A. Watkins, Farshad Mazda Shirazi, Miguel C. Fernández, Greg Hess, Jason Mihalic, Susan Runcorn, Victor Waddell, Jana Ritter, Sarah Reagan-Steiner, Jerry Thomas, Luke Yip, Frank G. Walter
A 35-year-old male presented to an emergency department 17.5 h after subcutaneously and intramuscularly injecting his forearm, deltoid, and shin with filtrate from an aqueous slurry of ∼150 A. precatorius seeds in a suicide attempt (Figure 1). He had GCS 15 with heart rate 114 beats/minute (bpm), blood pressure 101/66 mmHg, respiratory rate 18 breaths/minute, and temperature 35.3 °C. All injection sites exhibited erythema, edema, warmth, tenderness, and induration worst in his forearm (Figure 2). Initial labs and imaging were normal except white blood cells 41,600/mm3 (normal 4.0–11.0) and international normalized ratio (INR) 1.5 (normal 0.9–1.1). Intravenous antibiotics were administered for possible sepsis. Surgeons evaluated for compartment syndrome and necrotizing fasciitis, but fasciotomy was deemed unnecessary. CHP was considered because abrin is unlikely to pass across a hemodialysis membrane; however, charcoal cartridges were unavailable.
Streptococcal toxic shock syndrome in a returning traveller
Published in Acta Clinica Belgica, 2019
Stéphanie Note, Patrick Soentjens, Marie Van Laer, Philippe Meert, Peter Vanbrabant
Cutaneous manifestation is a common finding in TSS. Typically, the rash will be a diffuse, macular, sometimes pruritic erythroderma, often present at onset of disease [2]. Desquamation of the palms and soles typically develops 1 to 3 weeks later. Superficial ulcerations may occur in severe cases. Non-pitting oedema due to capillary leak can be present [2]. If the pain exceeds what is expected based on clinical examination, and especially at appearance of purpura or ecchymotic plaques, necrotizing fasciitis needs to be suspected [13–15]. If further investigation appears negative, histology can guide into the direction of acute infectious purpura fulminans, as presented in this case. Purpura fulminans is a life-threatening syndrome marked by DIC and endovascular thrombosis, resulting in the characteristic pattern of cutaneous purpura, associated to multiple-organ failure [14–16]. Purpura fulminans can be related to an anticoagulant protein deficiency or a post-infectious context, but most commonly occurs as a severe complication in the acute phase of infection [15,16]. Typically, gram-negative bacteria are the causal organisms, but reports of association with a streptococcal infection were made [16–18].
A review of post-caesarean infectious morbidity: how to prevent and treat
Published in Journal of Obstetrics and Gynaecology, 2018
Rebecca C. Pierson, Nicole P. Scott, Kristin E. Briscoe, David M. Haas
Necrotising fasciitis is a surgical emergency. Patients found to have extensive necrosis and/or fascial dehiscence upon probing of the opened or dehisced wound should be evaluated in the operating room in order to fully drain any seroma or haematoma, surgically debride the necrotic tissue and evaluate for necrotising processes. If necrotising fasciitis is not evident, the decision must be made regarding fascial closure: if sufficient viable tissue is present to allow primary closure without undue tension on the suture line, the fascia may be closed (Cliby 2002). If the fascia cannot be closed without excessive tension, a mesh bridge can be placed (Cliby 2002). Non-surgical management of fascial dehiscence is appropriate if the patient is unstable or has significant oedema (Cliby 2002), but primary closure should be accomplished when possible as the occurrence of incisional hernia is nearly guaranteed if the fascia is not closed primarily (van Ramshorst et al. 2010). A small study outlines a protocol using NPWT to decrease the time to primary fascial closure (Suliburk et al. 2003).