Necrotizing Fasciitis – "Don’t miss" as patient can quickly be severely harmed. Diagnosis is physical: Necrotizing fasciitis is an uncommon but life-threatening condition that carries a high risk of mortality and associated complications. It requires a high index of suspicion in order for it to be correctly diagnosed. Organisms invade a wound site and spread along the superficial and deep fascial planes causing a necrotizing infection. Necrotizing fasciitis should be urgently considered in any patient presenting with:
- a soft tissue infection or wound
- prominent pain or numbness over the infected area
and/or
- sepsis including tachycardia, hypotension and fever.
Necrotizing fasciitis infections can be classified into these types:
Type 1 – polymicrobial infection consisting of aerobic and anaerobic bacteria (Bacteroides,Peptostreptococcus, Eschericia coli, Klebisella) that is usually seen in immunocompromised patients or those with chronic disease.
Type 2 – is a monomicrobial infection of streptococus infection caused by group A steptococcus which can occasionally present with a staphylococcal infection. It can also be caused by vibrio vulnificus and aeromonas hydrophila which are marine organisms and can enter a wound following seawater contamination of wounds. These marine organisms are quite virulent and can be fatal or cause devastating consequences if not picked up quickly.
Risk factors to be considered when diagnosing Necrotizing fasciitis include:
- Varicella zoster infection - the lesions allow organisms to enter the body
- Traumatic (cut, wound) or nontraumatic cutaneous lesion (eczema, psoriasis, skin ulcer which allows entry for the bacteria
- Intravenous drug use leaves a puncture mark where organisms can break through
Key symptoms to look out for are:
- cutaneous lesion
- severe pain over site of wound or cellulitis – it should be noted that the pain experienced by the person may be disproportionate to the visible skin changes. Necrotizing fasciitis can occur in the extremities, perineum, trunk, head, neck and abdominal areas.
- fever
- palpitations
- dizziness
- hypotension
- nausea
- vomiting
- delirium
Have a high suspicion for Necrotizing fasciitis if the patient has encountered any of the following:
- Unexplained limb pain
- Systemically ill with severe pain
- Enquire about recent illness, exposure to sea water, fish stings or intraveous drug abuse
As this is a rapid developing infection, if necrotizing fasciitis is suspected then surgical exploration and debridement is needed along with administering broad spectrum antibiotics as the diagnosis is clinical. Further tests on CBC, CRP etc. can be carried out as time allows but visualisation of the tissues during surgery will show a necrotizing soft tissue infection which is diagnostic of this disease.
Using a diagnosis checklist system like Isabel will alert clinicians to consider these urgent don’t miss diagnoses and to positively rule them in or out of their differential diagnosis or ddx checklists to ensure the best outcome for their patients. Necrotizing fasciitis has to be treated quickly to prevent death and other complications like loss of limbs or damage to the body and its organs.
Isabel decision support showing red flagged don’t miss diagnosis of Necrotizing fasciitis for a patient presenting with a leg cut associated with intense pain
~Mandy Tomlinson, Isabel Quality Assurance Director
The Aimee Copeland story in the news about her ziplining accident into brackish waters when she contracted necrotizing fasciitis, an aggressive flesh-eating bacteria brought back awful memories for me. This is what happened to my daughter, Isabel, and was the inspiration for the start of Isabel Healthcare and the Isabel diagnosis checklist system.
I really feel for the Copeland family as their daughter fights for her life. In the space of a few days their lives have been turned upside down and will never be the same again. It appears that Aimee herself is still not conscious and may not be aware of all that has happened to her.
As you may expect, I have read the accounts of what happened, and it appears that, as with Isabel herself, the doctors should have gotten there quicker. Severe pain and or fever after the large cut should have rung alarm bells. Necrotizing Fasciitis (NF) is quite rare and the local clinicians who cared for Aimee had probably not seen a case of it before then, so they did not think of NF as a possibility -- until it was too late.
This is precisely why, after my daughter's case, it seemed obvious that all clinicians should have a diagnosis checklist system to help avoid them missing cases like this. 12 years ago these tools were not practical and not readily available. Today they are and this case vividly demonstrates once again why differential diagnosis or ddx tools should be part of routine care and provided by all healthcare institutions to their clinicians.
Today, with Aimee fighting for her life, I ask myself how much longer will it be before the medical profession accepts the need for these tools. How many more Aimees will it need?
Jason Maude
In chess, grand masters are even better with computers; in medicine doctors are better with differential diagnosis support (ddx) tools.
I recently read this story about chess and was struck by the parallels between medicine and the use of differential diagnosis or ddx tools like Isabel.
“Few would dispute that the chess achievements of Garry Kasparov are second to none. In spite of Kasparov’s success, he is unfairly best remembered as being the first world champion to lose a match against a computer - IBM’s Deep Blue in 1997. The news kicked up a media firestorm that challenged the superiority of the human mind over computers. However, it is actually two lesser-known games that Kasparov played against human opponents that are most instructive for the physician.
Kasparov has explained that, having lost to Deep Blue in 1997, he became fascinated with ‘Moravec’s Paradox’ or the fact that what computers are good at, humans are weak at and vice versa. Computers are excellent at calculation and computation, but humans have far higher levels of strategic intuition, sacrificial awareness and pattern recognition. What if instead of pitting one against the other, the man and machine played in tandem - could it create the highest level of chess ever played? In 1998 he and another Grandmaster Veselin Topalov played a match in this way armed with laptops loaded with software. While a month earlier Kasparov had beaten Topalov 4–0, in this instance the match ended a 3–3 draw. When both were armed with machines, Topalov had managed to draw level in skill with the usually superior Kasparov.”
Computers can certainly aid in improving medical diagnosis. This concept is clear from the stories we get from Isabel ddx users, specifically shown in the research from Rosalind Franklin Medical School that showed that their Year 4 medical students improved their diagnosis accuracy by over 20% (1). A ddx tool like Isabel helps make smart docs even smarter.
1 The Impact of a diagnostic reminder system on student clinical reasoning during simulated case studies. Carlson J, Abel M, Bridges D, Tomkowiak J.
Not too long ago, the public’s perception of a nurse was someone who cared for you when you were hospitalized, offered comfort at a time when you most needed it and carried out requests that doctors had made. Doctors were responsible for making clinical decisions, and a nurse was seen as a “handmaiden” who carried out the doctors' requests. Wards were run with military precision. Patients were washed, dressed and beds made (with perfect hospital corners!) by a set time each day. The nursing staff were in fear of the matron who made her rounds to ensure that all was done according to protocol and that you were perfectly turned out in your starched nursing uniform and cap.
How things have changed! Nurse training has evolved, and nurses are taking on extended roles including further study to become Nurse Practitioners or advanced courses in particular specialities. In the US today, according to the American Academy of Nurse Practitioners (AANP) there are 115,000 Nurse Practitioners, and the majority work in primary care.
The Nurse Practitioner's role today includes taking clinical histories, performing physical examinations, ordering tests and interpreting results to rule in or rule out diseases, liaising with members of the multidisciplinary team about the patient and what course of action or treatment should be taken in the patient’s clinical care. These responsibilities are in addition to the core values of nursing which have underpinned the profession for many years:
- To promote health, healing and well-being, prevent disease and illness, minimize distress, suffering and assist people in adapting to their disease, if death is inevitable then provide the best quality of life for the patient, assist patients with their health, social, spiritual and psychological needs.
- To act as an advocate and in partnership with the patient and their family and to work within a multidisciplinary team to ensure the patient receives the best quality of care and outcomes possible.
Nurses are at the frontline with patients and their families 24 hours a day, seven days a week. They are responsible for a specific group of patients and plan their care, detect changes in their conditions and then act on these changes to ensure the appropriate intervention is actioned.
You can walk into a ward or clinic today and see many health professionals taking blood work, prescribing and administering medication, carrying out physical examinations, presenting on ward rounds, breaking bad news to a patient or their family, carrying out procedures involving cannulation, central venous catheters, chest drains and administering emergency medication. These could equally be interventions being carried out by a Doctor or a Nurse.
Happy National Nurses week. Be proud and enjoy how your profession has evolved and continues to evolve. In any one working day remember you are an advocate, colleague, team member, life saver, clinical expert, counsellor, researcher, carer, leader and a friend.
~Mandy Tomlinson, RN, Isabel Quality Assurance Director
See how other nurses have used Isabel. View the Video now: Nurse Practioners Rely on Isabel
The Isabel Healthcare 1 Minute Read program highlights various diseases and conditions, providing the Isabel tool differential list. Subscribe to the Isabel blog to receive clinical content and articles.
Abdominal Pain Differential Diagnosis
With abdominal pain, it is important to determine what the cause is by taking a good history and the cause of the pain -- like how the pain begins, the location, pattern of the pain, the duration of the pain, and if anything causes or relieves the pain. The examination of the patient will allow for tenderness to be felt and to identify if any mass exists. A stomach ache normally refers to abdominal cramps or a dull ache in the abdomen and can be self-limiting and resolve quickly if caused by Gastroenteritis. Severe abdominal pain indicates pain arising from the abdomen and could originate in the abdominal wall but can also arise from organs contained within the abdominal cavity like the stomach, pancreas or appendix. Severe abdominal pain is a significant symptom as could require surgical or medical intervention and should be fully investigated.
Abdominal Pain Causes
Potential causes of abdominal pain including red flagged or "don’t miss" diagnoses which should be ruled in or ruled out quickly, as they could require urgent medical/surgical intervention:
Pancreatitis can present with severe upper abdominal pain radiating to the back, nausea and vomiting.
Peritonitis can occur suddenly with severe abdominal pain, chills and high fever.
Recurrent abdominal pain presents in children with wax and waning abdominal pain, three episodes within a three month period and is severe enough to interfere with a child’s activities. It is fairly common and difficult to diagnose as not accompanied by easily definable organic pathology but can cause a lot of disruption to the child.
Acute appendicitis should be considered in any child presenting with abdominal pain which starts in the middle of the abdomen and then transfers to the lower right quadrant of the abdomen where the appendix normally lies. The pain worsens as the appendix becomes more inflamed and other symptoms may be fever and vomiting. Occasionally constipation or diarrhea may develop.
Urinary tract infection normally present with the urge to urinate frequently, a painful burning sensation when urinating, abdominal pressure or discomfort and sometimes pain in the lower back.
Tests can help determine the actual diagnosis or cause of the abdominal pain by carrying out full blood counts, checking liver and pancreatic enzymes and performing a urinalysis. Other investigations which may be deemed necessary include an abdominal xray, abdominal ultrasound, MRI, barium xray or CT.
As Isabel is not a rules-based system, it is possible to use Isabel’s natural language processing abilities to obtain a differential diagnosis checklist using other terms like “cramping abdominal pain” which describes the nature of the pain more accurately and potentially narrow the disease list as the symptom is more specific and due to the differential checklist of abdominal pain spanning many specialities of medicine.
Its also possible to concentrate on a specific part of the abdomen affected like “lower right quadrant abdominal pain” and obtain a differential checklist.
There are many benign causes of abdominal pain but if pain develops suddenly, is severe or is prolonged, then it is important to determine the cause as soon possible and treat accordingly.
~by Mandy Tomlinson, RN, Isabel Quality Assurance Director
The
Isabel diagnosis tool touts an extensive database of conditions for differential diagnosis support, and we often will test its accuracy with real patient cases from the New England Journal of Medicine.
About the Isabel Diagnosis Challenge
The New England Journal of Medicine (NEJM) publishes interesting presentations of common diseases and unusual cases in the Clinical pathology Conference (CPC) series. These cases are educational and can pose diagnostic challenges even to the expert physicians at the Massachusetts General Hospital.
Using the clinical features of these cases you can evaluate your own diagnostic skills and compare your diagnostic performance to that of the physicians at MGH. If you are registered with Isabel as a client or have a free-trial subscription, you can use the diagnosis reminder system and run through some scenarios to get a list of likely suspects. Clicking on a diagnosis will take you through to various knowledge sources and links available from within Isabel.
Today's Case
#12:3 N Engl J Med. 366(4):361-372
Demographic: Male, Neonate, North America
Clinical features:
- bilious vomiting
- bloody diarrhea
- fever
- failure to pass meconium
- abdominal distention
- lethargy
- heme-positive stool
- septic shock
STOP !
Before you read further, construct your own: 1) Complete differential diagnosis and 2) Final diagnosis
Differential Diagnoses considered by the MGH panel: Volvulus Necrotising enterocolitis
Final Diagnosis of the case according to NEJM: Hirschsprung’s disease with enterocolitis
Differential Diagnoses of the case as given by the Isabel tool: Volvulus in Gastro, Necrotising enterocolitis in Infectious
Was the final diagnosis given by Isabel: Yes, Hirschsprung’s disease under large bowel obstruction in Gastro
The Isabel Healthcare 1 Minute Read program highlights various diseases and conditions, providing the Isabel tool differential list. Subscribe to the Isabel blog to receive clinical content and articles.
The Case Record 12 (2012) of the Massachusetts General Hospital in the New England Journal of Medicine details a 10 month old girl presenting to the emergency department due to vomiting and unresponsiveness which had begun 7 hours earlier. The baby became more somnolent, and after further work up and tests, she was diagnosed with Ileocolonic intussusception associated with syncope (neurologic intussusception).
Intussusception is a major cause of intestinal obstruction in young children, and it occurs when a portion of bowel slides into the next part of the bowel (like a telescope) which creates a bowel blockage which leads to swelling, inflammation and decreased blood flow to the intestinal parts involved. It is a medical emergency which should be treated quickly, and it is therefore important to ensure that Intussusception is appropriately considered when constructing a differential for a baby presenting between age 3 months to 3 years with any of the key symptoms such as abdominal pain, vomiting, lethargy, irritability, blood per rectum, pallor or palpable abdominal mass and tests should be performed to rule in or rule out this diagnosis.
The peak age of incidence is 7 months, and 75% of cases are diagnosed in children under a year. Boys are more commonly affected than girls at a ratio of 3:2. The baby tends to have colicky abdominal pain lasting for 1 to 3 minutes and in between these episodes the baby behaves normally.
Vomiting can be nonbilious or bilious, lethargy or irritability can sometimes be the only presenting complaint. Other late symptoms or indicators of severe disease which take longer than 24 hours to develop are occult blood per rectum or frank blood and mucus resembling currant jelly, intractable vomiting, abdominal distention or hypovolemic shock. Therefore identifying Intussusception early is the key to a good prognosis.
It may be possible to feel a palpable abdominal mass (sausage shaped mass) in the right upper quadrant or epigastrium. Guaiac-positive stools may be found and occasionally a rectal mass may be palpable or a prolapse through the anus may be seen. Other less common symptoms which the baby may present with include diarrhea or poor feeding.
Other conditions to rule out are appendicitis (rectal bleeding is not present, intussusception is more colicky abdominal pain than the abdominal pain seen in appendicitis), gastroenteritis, UTI (this can be easily confused with Intussusception) and pyloric stenosis (typically appears between 2 and 12 weeks and presents with projectile nonbilious vomiting after feeding).
To confirm Intussusception in a baby with any of the symptoms mentioned, an abdominal plain x-ray should be carried out which may appear normal but could show an abdominal mass, abnormal gas pattern, air-fluid levels, dilated bowel loops, empty right lower quadrant, “Target sign”, free intra-abdominal air. Other tests to consider are ultrasound and diagnostic enema.
Once diagnosed then treatment should begin immediately to prevent the condition worsening with appropriate fluid resuscitation. Depending on how clinically stable the baby is, then contrast enema reduction or immediate surgical reduction should be carried out.
A key way to support the early diagnosis of Intussusception is to use a diagnosis checklist tool for the symptoms the child presents with to remind medical practitioners that these are key symptoms that occur in this condition and any young child meeting the criteria for age (under 3 years) and symptom(s) mentioned earlier should be acted upon quickly. The condition ruled out as early diagnosis is the key to improved outcome. See the diagnosis tool applied to this condition below in the graphic:
In the Case Record 12 (2012) of the Massachusetts General Hospital, using the Isabel diagnosis system (graphic above) with the symptoms the baby presented with, Intussusception is on the list of likely diagnoses and is red flagged indicating the seriousness of the condition and that further appropriate tests carried out to rule it in or out immediately.
The typical appearance of an intussusception in a patient with Peutz-Jeghers-Syndrome (intestinal polyposis) after contrast enema: the so-called coil-spring appearance and cupping in the head of barium.
Fluoroscopy image during air enema demonstrating a large soft tissue mass in the region of the caecum representing the intussusception (the patient is lying prone hence the caecum lies on the right side of the image).
Request a demo of Isabel or click below to try it free for 10 days.
One of the most tragic cases of diagnosis I have ever seen was widely reported in the UK last week. This article in the Daily Mail is the most detailed as the reporter had clearly read the judgement that was also published. In brief, the case deals with a young couple whose child died after presenting with seizures due to a fractured skull. The clinicians presumed the fractured skull to be as a result of child abuse and the parents were charged with murder. Both parents were wrongly imprisoned for some months but were finally cleared of murder after it was revealed that the child had rickets due to vitamin D deficiency and that the fracture was most likely due to the child banging its head while in its cot. The couple also had a second child that was born before they were cleared at trial, and she was immediately removed from them. Although acquitted of murder at the trial, the parents had to go through another court case to regain custody of their daughter. They finally won this case last week and are now back at home with their daughter!
The case is particularly tragic because the missed diagnosis of rickets may have been prevented, and it shows that this wrong initial step can lead to a cascade of awful events. The case is also a classic one of "premature closure" as the clinicians jumped to the conclusion of child abuse and then failed to consider any other reasonable possibilities. The judgement is extremely detailed and includes statements from several expert witnesses so enables us to see that there was virtually no discussion or consideration of any other possible diagnoses. The judgement also shows that the young couple appeared to be perfect parents with Jayden not showing any signs whatsoever of abuse.
Just by entering any one or a combination of Jayden’s symptoms: “seizures”, “fractured skull” or “low calcium” into Isabel (or the new iPhone app) may have reminded doctors to consider rickets as another important possible diagnosis. Instead, the diagnosis of “child abuse” was made to the exclusion of other likely and important diagnoses, triggering the cascade of horrific events to hit the family over the last three years. This case illustrates graphically why the use of tools like Isabel should become standard practice.
In the 21st century, when virtually every other industry is heavily reliant on information technology, our health should not be so dependent on a doctor’s memory and subjective views. In my view, hospitals and practices should be required to provide diagnosis checklist tools to support their clinicians in the same way that other tools are provided.
~by Jason Maude, Isabel Healthcare Founder
The Isabel tool touts an extensive database of conditions for differential diagnosis support, and we often will test its accuracy with real patient cases from the New England Journal of Medicine.
About the Isabel Diagnosis Challenge
The New England Journal of Medicine (NEJM) publishes interesting presentations of common diseases and unusual cases in the Clinical pathology Conference (CPC) series. These cases are educational and can pose diagnostic challenges even to the expert physicians at the Massachusetts General Hospital.
Using the clinical features of these cases you can evaluate your own diagnostic skills and compare your diagnostic performance to that of the physicians at MGH. If you are registered with Isabel as a client or have a free-trial subscription, you can use the diagnosis reminder system and run through some scenarios to get a list of likely suspects. Clicking on a diagnosis will take you through to various knowledge sources and links available from within Isabel.
Today's Case
Demographic: Female, 63 yrs, Not pregnant, North America
Clinical features:
- respiratory failure
- chest wall mass
- dyspnea on exertion
- thrombocytopenia
- large ecchymoses
- non-productive cough
- decreased oxygen saturation
- alveolar haemorrhage
- pulmonary infiltrates
STOP !
Before you read further, construct your own:
- Complete differential diagnosis
- Final diagnosis
Final Diagnosis of the case according to NEJM:
- Angiosarcoma of the chest wall associated with a silicone breast implant
- Kasabach-Merritt syndrome
- Invasive pulmonary aspergillosis
Was the final diagnosis given by Isabel: Yes:
- Lung neoplasms in Respiratory
- Kasabach-Merritt syndrome
- Invasive pulmonary aspergillosis under Aspergilliosis in Infectious
#12:1. The Isabel tool touts an extensive database of conditions for differential diagnosis support, and we often will test its accuracy with real patient cases from the New England Journal of Medicine.
About the Isabel Diagnosis Challenge
The New England Journal of Medicine (NEJM) publishes interesting presentations of common diseases and unusual cases in the Clinical pathology Conference (CPC) series. These cases are educational and can pose diagnostic challenges even to the expert physicians at the Massachusetts General Hospital.
Using the clinical features of these cases you can evaluate your own diagnostic skills and compare your diagnostic performance to that of the physicians at MGH. If you are registered with Isabel as a client or have a free-trial subscription, you can use the diagnosis reminder system and run through some scenarios to get a list of likely suspects. Clicking on a diagnosis will take you through to various knowledge sources and links available from within Isabel.
Today's Case
Demographic: Male, 82 yrs, North America
Clinical features:
- Skin lesions on hand
- dog bite
- hand erythema
- violaceous bullous
- hand lesion
- urticarial and purpuric rash on torso
- thrombocytopenia anemia
- leukocytoclastic vasculitis
- weight loss
- intermittent diarrhea
STOP !
Before you read further, construct your own:
- Complete differential diagnosis
- Final diagnosis
Differential Diagnoses considered by the MGH panel: Sweet’s syndrome
Final Diagnosis of the case according to NEJM: Pyoderma gangrenosum due to myelodysplastic syndrome
Differential Diagnoses of the case as given by Isabel: Sweet’s syndrome under Neutrophilic dermatoses in Rheumatology
Was the final diagnosis given by Isabel:
Yes, Pyoderma gangrenosum under Neutrophilic dermatoses in Rheumatology
