Patient Requires Amputation Following Several Emergency Room Visits

    Emergency Medicine Expert

    This case involves a woman with a history of aortic aneurysm who presented to the emergency room with foot pain. The patient was diagnosed with a skin infection, given an Amoxicillin prescription, and discharged. The patient returned to the emergency room several days later with worsening foot pain and the attending noted that both her feet and both her knees were red with a rash. The patient was diagnosed with vasculitis, prescribed clindamycin and discharged. Two weeks later, the patient returned to the hospital with an ulcer on her right foot. It was discovered that the patient had been throwing septic emboli from her infected aortic aneurysm stent. A vascular surgeon was consulted and a below-knee amputation was the only option. An expert emergency medicine physician was sought to review the records and opine on the standard of care for patients with bilateral foot pain under these circumstances.

    Question(s) For Expert Witness

    • 1. What is your experience evaluating patients with bilateral foot pain and knee erythema in the emergency room?
    • 2. What are the indications for admitting a patient with bilateral foot and knee pain, erythema and a macular rash?
    • 3. What is the standard work-up that should be performed by the ED physician in a patient with these signs/ symptoms?

    Expert Witness Response E-025783

    I am a practicing academic emergency physician. I see patients with this chief complaint (foot or knee pain) on a regular basis. I also have a masters degree in medical research and am fellowship-trained. This added training has given me specific skills that lend themselves well to meticulous review and careful analysis of cases such as these. I have reviewed several cases for medico-legal purposes and have had nothing but positive feedback from lawyers.

    I have seen many patients with foot pain in the emergency department. I have seen many patients with knee erythema. The combination of both is more rare, however.
    Concern for a vascular cause such as arterial insufficiency or embolism would prompt a CT angio of the legs to be obtained. If confirmed, then the patient would be admitted for heparin to a vascular surgeon. If the cause was an infection, and the patient had failed oral outpatient therapy, such as Amoxicillin, then the patient would be admitted for IV anitbiotics. If the patient had signs of sepsis, then the patient would be admitted. Basic labs would be ordered including blood cultures if febrile. If a vascular cause such as leg ischemia was suspected, then a CT angio of the legs would be obtained. If poliomyelitis was suspected, an X-ray or CT of the feet would be obtained. If the knee was warm and swollen with fever, then a knee arthrocentesis would be done.

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