Necrotizing fasciitis physical examination: Difference between revisions
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==Overview== | ==Overview== | ||
Physical examination of patients with necrotizing fasciitis is usually remarkable for local soft tissue signs such as warmth, tenderness beyond margins of [[erythema]], swelling, [[erythema]] with ill defined margins, [[blister|blistering]]/bullae, skin discoloration, foul discharge (greyish or brown discharge), fluctuance, [[crepitus]], skin sloughing or [[necrosis]], absence of [[lymphangitis]] or [[lymphadenopathy]] ([[lymphangitis]] is rarely observed in necrotizing fasciitis patients), sensory and motor deficits (e.g. [[anesthesia|localized anesthesia]]).<ref name="pmid15918785">{{cite journal| author=Young MH, Aronoff DM, Engleberg NC| title=Necrotizing fasciitis: pathogenesis and treatment. | journal=Expert Rev Anti Infect Ther | year= 2005 | volume= 3 | issue= 2 | pages= 279-94 | pmid=15918785 | doi=10.1586/14787210.3.2.279 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15918785 }} </ref><ref name="pmid19826154">{{cite journal| author=Puvanendran R, Huey JC, Pasupathy S| title=Necrotizing fasciitis. | journal=Can Fam Physician | year= 2009 | volume= 55 | issue= 10 | pages= 981-7 | pmid=19826154 | doi= | pmc=2762295 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19826154 }} </ref> Finger probe test is useful in the diagnosis of necrotizing fasciitis.<ref name="pmid19826154">{{cite journal| author=Puvanendran R, Huey JC, Pasupathy S| title=Necrotizing fasciitis. | journal=Can Fam Physician | year= 2009 | volume= 55 | issue= 10 | pages= 981-7 | pmid=19826154 | doi= | pmc=2762295 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19826154 }} </ref> | |||
==Physical Examination== | ==Physical Examination== | ||
Common physical examination findings associated with necrotizing fasciitis may include: | Common physical examination findings associated with necrotizing fasciitis may include:<ref name="pmid15918785">{{cite journal| author=Young MH, Aronoff DM, Engleberg NC| title=Necrotizing fasciitis: pathogenesis and treatment. | journal=Expert Rev Anti Infect Ther | year= 2005 | volume= 3 | issue= 2 | pages= 279-94 | pmid=15918785 | doi=10.1586/14787210.3.2.279 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15918785 }} </ref><ref name="pmid19826154">{{cite journal| author=Puvanendran R, Huey JC, Pasupathy S| title=Necrotizing fasciitis. | journal=Can Fam Physician | year= 2009 | volume= 55 | issue= 10 | pages= 981-7 | pmid=19826154 | doi= | pmc=2762295 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19826154 }} </ref> | ||
===Appearance of the patient=== | |||
Patients with necrotizing fasciitis appear fatigued during early stages and may have altered mental status during late stages. In end stage necrotizing fasciitis, patients exhibit signs of septic shock. | *Patients with necrotizing fasciitis appear [[fatigue|fatigued]] during early stages and may have [[altered mental status]] during late stages. In end stage necrotizing fasciitis, patients exhibit signs of [[septic shock]]. | ||
===Vital signs=== | |||
*Fever ( | *[[Fever]] (may be absent) | ||
*Tachycardia | *[[Tachycardia]] | ||
*Low blood pressure | *[[Low blood pressure]] | ||
*Tachypnea | *[[Tachypnea]] | ||
===Skin=== | |||
*[[Jaundice]] | |||
*Evidence of [[trauma]], surgery, insect or human bites, or injection sites | |||
===Local examination=== | |||
*[[Induration]] | |||
*Induration | |||
*Warmth | *Warmth | ||
*Tenderness beyond margins of erythema | *Tenderness beyond margins of [[erythema]] | ||
*Swelling | *[[Swelling]] | ||
*Erythema with ill defined margins | *[[Erythema]] with ill defined margins | ||
*Blistering/bullae | *[[Blister|Blistering]]/bullae | ||
*Skin discoloration | *Skin discoloration | ||
*Foul discharge (greyish or brown discharge) | *Foul discharge (greyish or brown discharge) | ||
*Fluctuance | *Fluctuance | ||
*Crepitus | *[[Crepitus]] | ||
*Skin sloughing or necrosis | *Skin sloughing or [[necrosis]] | ||
*Absence of | *Absence of [[lymphangitis]] or [[lymphadenopathy]] ([[lymphangitis]] is rarely observed in necrotizing fasciitis) | ||
*Sensory and motor deficits (e.g. localized anesthesia) | *Sensory and motor deficits (e.g. [[anesthesia|localized anesthesia]]) | ||
{| class="wikitable" | {| class="wikitable" style="text-align:left" | ||
|- | |- | ||
! Stage | ! Stage | ||
(Early) | (Early) | ||
! | ! Signs | ||
|- | |||
| Early | |||
| ● [[Tenderness]] to [[palpation]] (extending beyond the apparent area of skin involvement) <br> ● [[Erythema]] <br> ● Swelling <br> ● Warm to palpation | |||
( | |||
|- | |- | ||
| | | Intermediate | ||
| ● [[Blister]] or bullae formation ([[serous fluid]]) <br> ● Skin fluctuance <br> ● Skin [[induration]] | |||
|- | |||
| | | Late | ||
| Hemorrhagic bullae <br>Skin anesthesia <br>Crepitus <br>Skin necrosis with dusky discoloration progressing to frank gangrene | | ● Hemorrhagic bullae <br> ● [[Anesthesia|Skin anesthesia]] <br> ● [[Crepitus]] <br> ● Skin [[necrosis]] with dusky discoloration progressing to frank [[gangrene]] | ||
|- | |- | ||
|} | |} | ||
===Finger Probe Test=== | |||
*Finger probe test is useful in the diagnosis of necrotizing fasciitis.<ref name="pmid19826154">{{cite journal| author=Puvanendran R, Huey JC, Pasupathy S| title=Necrotizing fasciitis. | journal=Can Fam Physician | year= 2009 | volume= 55 | issue= 10 | pages= 981-7 | pmid=19826154 | doi= | pmc=2762295 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19826154 }} </ref> | |||
====Procedure==== | |||
:*This test is carried out in the ward, emergency room and in the theatre under [[Anesthesia|local]] or [[general anesthesia]]. | |||
:*After infiltrating the area, a 2cm incision is made down to the [[fascia|deep fascia]]. | |||
:*Fascia will be swollen and grey on gross inspection. | |||
:*Gentle probing with index finger is performed at the level of deep fascia and if the tissue dissects with the minimal resistance, then finger probe test is considered positive. | |||
:*Signs suggesting necrotizing fasciitis include: | |||
:**Lack of [[bleeding]] | |||
:**Lack of normal tissue resistance on finger probe | |||
:**Oozing of malodorous "dish water fluid" | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category:Emergency mdicine]] | |||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category: | [[Category:Up-To-Date]] | ||
[[Category:Infectious disease]] | [[Category:Infectious disease]] | ||
[[Category:Surgery]] | |||
[[Category:Orthopedics]] | |||
Latest revision as of 22:56, 29 July 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[2]
Overview
Physical examination of patients with necrotizing fasciitis is usually remarkable for local soft tissue signs such as warmth, tenderness beyond margins of erythema, swelling, erythema with ill defined margins, blistering/bullae, skin discoloration, foul discharge (greyish or brown discharge), fluctuance, crepitus, skin sloughing or necrosis, absence of lymphangitis or lymphadenopathy (lymphangitis is rarely observed in necrotizing fasciitis patients), sensory and motor deficits (e.g. localized anesthesia).[1][2] Finger probe test is useful in the diagnosis of necrotizing fasciitis.[2]
Physical Examination
Common physical examination findings associated with necrotizing fasciitis may include:[1][2]
Appearance of the patient
- Patients with necrotizing fasciitis appear fatigued during early stages and may have altered mental status during late stages. In end stage necrotizing fasciitis, patients exhibit signs of septic shock.
Vital signs
- Fever (may be absent)
- Tachycardia
- Low blood pressure
- Tachypnea
Skin
Local examination
- Induration
- Warmth
- Tenderness beyond margins of erythema
- Swelling
- Erythema with ill defined margins
- Blistering/bullae
- Skin discoloration
- Foul discharge (greyish or brown discharge)
- Fluctuance
- Crepitus
- Skin sloughing or necrosis
- Absence of lymphangitis or lymphadenopathy (lymphangitis is rarely observed in necrotizing fasciitis)
- Sensory and motor deficits (e.g. localized anesthesia)
| Stage
(Early) |
Signs |
|---|---|
| Early | ● Tenderness to palpation (extending beyond the apparent area of skin involvement) ● Erythema ● Swelling ● Warm to palpation |
| Intermediate | ● Blister or bullae formation (serous fluid) ● Skin fluctuance ● Skin induration |
| Late | ● Hemorrhagic bullae ● Skin anesthesia ● Crepitus ● Skin necrosis with dusky discoloration progressing to frank gangrene |
Finger Probe Test
- Finger probe test is useful in the diagnosis of necrotizing fasciitis.[2]
Procedure
- This test is carried out in the ward, emergency room and in the theatre under local or general anesthesia.
- After infiltrating the area, a 2cm incision is made down to the deep fascia.
- Fascia will be swollen and grey on gross inspection.
- Gentle probing with index finger is performed at the level of deep fascia and if the tissue dissects with the minimal resistance, then finger probe test is considered positive.
- Signs suggesting necrotizing fasciitis include:
- Lack of bleeding
- Lack of normal tissue resistance on finger probe
- Oozing of malodorous "dish water fluid"
References
- ↑ 1.0 1.1 Young MH, Aronoff DM, Engleberg NC (2005). "Necrotizing fasciitis: pathogenesis and treatment". Expert Rev Anti Infect Ther. 3 (2): 279–94. doi:10.1586/14787210.3.2.279. PMID 15918785.
- ↑ 2.0 2.1 2.2 2.3 Puvanendran R, Huey JC, Pasupathy S (2009). "Necrotizing fasciitis". Can Fam Physician. 55 (10): 981–7. PMC 2762295. PMID 19826154.