[Eydawn]

Howdy folks... I guess it had to happen sooner or later, but I'm questioning my LPN's decision to chart something as a bruise when I think that it is cellulitis. I see this as a purely teachable moment; once I report something to nursing, it's their ball from there and I can't really challenge them... but I want to know if my thinking on this is reasonable, and if I'm wrong, why I'm wrong and why the nurse is right.

Case: 65 y/o female with hx recurrent UTI's, recurrent skin yeast rash (turned bacterial a few weeks back and resulted in a hospital stay), pre-diabetic, obese, HTN, A-fib, depression, anti-coagulant therapy, lower extremity neuropathy. Pt has been on antibiotics off and on for UTI symptoms several times over last 2 months. Pt is prone to frequent falls and ambulates primarily with a power-scooter that she runs into stuff with all the time. Pt had a fall in her bathroom (unwitnessed) about 4 days ago.

Her lower right leg has a very large dark bruise just below her knee surrounded by a swollen area roughly 4" across and elevated ~1" and her entire lower extremity is now swollen. The skin on the anterior part of her leg is red and very warm to the touch and has a shiny appearance. I reported this yesterday, and it has been charted as a bruise with swelling, tx is NSAIDs for pain PRN and ice packs.

There are several things about this that are screaming cellulitis at me: The pt's lower leg neuropathy hx and recent infection issues, the fact that her entire lower leg is now displaying edema, the giant red blotch on her shin surrounding the swollen area that is shiny and hot... Correct me if I'm wrong, but can't cellulitis begin after a traumatic injury, especially in someone who's pre-diabetic with circulation issues?

I'm documenting what I see as I see it, as my charting is separate from my LPN's, and I can't "diagnose" (aka put that I suspect cellulitis) anywhere in my written documentation, but I have a sinking feeling that my LPN (who is fairly new as a nurse) is missing something here. Teach me! Is my LPN right? Could this just be a bruise with swelling? Am I over-thinking this? I feel so bad for this lady, she's had so much stuff happen (and some things get missed thru bad communication) that I'd hate for us to miss budding cellulitis... but I'm also hoping that my assessment is wrong.

Wendy
CO EMT-B

This post has been edited by Eydawn: 16 March 2010 - 11:32 AM

[Gypsy]

Yikes I think I might go deaf with how loud it's screaming! Yep that sounds like it to me too. My husband had cellulitis after being biten a few times by some unknown spiders. Those were his exact signs and symptoms so ya I would go with you being right.

[DwayneEMTP]

Gypsy, on 16 March 2010 - 04:22 AM, said:

Yikes I think I might go deaf with how loud it's screaming! Yep that sounds like it to me too. My husband had cellulitis after being biten a few times by some unknown spiders. Those were his exact signs and symptoms so ya I would go with you being right.

From the description it sounds like cellulitis, and not like any isolated bruise I've ever seen. She has multi system pathologies already, and it sounds like she's got issues secondary to regular antibiotic use. It also sounds like this isn't a terribly new onset cellulitis, if in fact that is what it turns out to be. If they don't jump on it really soon I'm not sure how they will treat this pt with cellulitis on an edematous extremity as well as an unrelated vasculopathy. Pretty tough to deliver antibiotics through compromised vasculature that's also being squished by edema.

I suppose it's possible that the trauma was deep enough to cause her some compartment issues and the swelling from the two is enough to cause the cellulitis like symptoms, but I would expect that to become cooler to the touch, not warmer. Yeah, I'm going with cellulitis. Plus, you're pretty smart for a girl...I wouldn't bet against you in any case.. :-)

Be an interesting case to follow if you're able.

Dwayne

[Richard B the EMT]

Wendy, please keep us posted, both as to the finalized diagnosis, and the patient's status.

[Eydawn]

Pt. went out to urgent care with her daughter this evening... bruising and swelling have both worsened, and she was diagnosed with another UTI... they gave her Keflex (cephalexin) both to treat the UTI and to treat for potential (non-confirmed) infection in her lower limb.

So... still no final word, but it looks like I was closer by thinking infection of some sort... pt is in good spirits, but that leg is still looking wicked bad.

Wendy
CO EMT-B