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.

Expert Witness Response E-008126

I see patients with foot and leg pain every shift in the ED. I evaluate patients with and for abdominal aortic aneurysm several times a month. The presence of a stent graft should lead the qualified emergency physician to consider graft leak, internally or externally, and septic and non-septic emboli. Any patient with a AAA repair is at high risk for peripheral arterial disease. Regarding the need for admission, if vasculitis is the diagnosis, the patient would usually be admitted as this requires consultation with an internist or rheumatologist and likely administration of steroids.There’s not enough info in the case vignette to determine the workup. Usually, the patient would get a CBC to check hematocrit and WBC, CMP to check liver and renal function, and CT of the abdomen with or without contrast depending on presentation and renal function. Consultation with vascular surgery would be customary if there is suspicion of emboli or PAD or AAA leak.

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