Right Leg Pain and Swelling and Redness and Warmth
46 yo female with sudden onset right lower leg pains and chills. No fevers and reports she gets chills at times but doesn’t feel well right now. Denies any trauma to the area. Feels it’s more swollen than usual. Hx of cellulitis in the same leg and hx of DVT in the same leg both diagnosed in the past 6 months. Currently on warfarin with INR at 2.0. She is able to walk but has moderate pains.
Chronic Right Leg Ulcer.
Hx of gastric bypass.
dexamethasone 4mg prn headache.
potassium chloride 10mEq.
sumatriptan 20mg nasal spray.
albuterol HFA 90mcg.
BP 153/91, Pulse 99, Temp 98.6 °F (37 °C) (Oral), Resp 20 , Wt 267 lb (121.11 kg), O2 sat 97%
On exam patient has 2+ mild pitting edema in the bilateral lower extremities.
Skin on the feet bilaterally dry with mild fissuring with some dry tinea pedis noted.
There is no ulcer noted on the right lower leg.
Moderate erythema with skin induration and moderate tenderness.
Unilateral erythema and skin induration and calor. Erythema with increased edema. Ulcer is healed, only granulation tissue.
Based on the diffuse erythema of the entire, the fact that it’s circumferential instead of just over the anterior portion of the shin like we see with acute venous stasis dermatitis (see this case for an example) I diagnosed her with cellulitis. She has had a history of sepsis due to other bacterial infection and she has had multiple hospitalizations in the past. Therefore she is at risk for MRSA as the cause of cellulitis. However, because of recent clindamycin use and risk for clostridium difficile I will start with cephalexin and monitor her progress with a 24 and 48 hour recheck. She was encouraged to start using her compression stockings again and increase her exercise.