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What Do I Do Next – A Fireman’s Story

Mike Weinstock, MD and Mizuho Morrison, DO
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No me gusta!

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Patients can present with shoulder pain to the UC, however it is absolutely critical that we consider not just musculoskeletal causes but other life threatening etiologies of shoulder pain. Here we review a true case, that bounce-backed with a terribly tragic missed diagnosis. You will be sucked in to this riveting story.

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Anita O. -

Hi, Love it so far. Last month discussion on not treating an abscess with antibiotics had me thinking.. maybe not. But this this case gives me a scare. Yes I understand that strep and staff are 2 different organisms but I'm not smart enough to tell the difference by just looking at a patient. I wonder if I should continue to treat my abscess with cellulitis with antibiotics for now. What are your thoughts Please help me sort this out...

Mizuho M., DO -

HI Anita,
Sorry for the delayed response!
Yes, we hear you! Sometimes these are tough to sort out. The good news is, that these 2 diagnosis (abscess vs. nec fasc) both come down to the clinical evaluation.
An abscess has a focal raised pus-filled "mass" or palpable area of infection. I&D is the treatment of choice, and if there is significant cellulitis associated, particularly in diabetics/immune suppressed one could consider adding antibiotics in these cases, however these are minority of cases. Most of the time antibiotics are not necessary.
Necrotizing fascitis, &/or other deep fascia/space infections do not have a raised "mass". It is more of a induration & erythema, and as it progresses, the soft tissue changes occur along a horizontal plane (in later stages, i.e.: subcutaneous emphysema etc). Abscesses should NOT have this appearance or palpable feel.

No one can clinically differentiate between Staph vs. Strep. And the good news is, you don't need to! Its irrelevant. These clinically appear very differently and also present very differently. Abscesses are generally more indolent in onset, and the pt should not be ill (i.e.: afebrile, no tachycardia etc). On the contrary nec fasc patients may initially be ok looking but as their cellulitis spreads, they will have concomitant fever, tachycardia, (sepsis), AMS etc.
I recommend looking at dermatology references to compare and contrast the visual differences in the 2 diagnosis. These cases are tough...and they scare us all! Which is why we like to review them. Mike and I pick out these cases intentionally to make us all stop, and think about what else this COULD be. Keep up the strong work!!! Thanks for the feedback! ~Miz

Anita O. -


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The Head: Eye issues, Migraine, Nasal foreign bodies, and Burnout Full episode audio for MD edition 223:23 min - 260 MB - M4AUrgentCare:RAP 2015 June Summary 950 KB - PDF