Bottom line
Hospitalists are in a unique position to identify patients with underlying peripheral arterial and venous disease when they are admitted for lower extremity skin and soft tissue infections. A focused history and physical exam can yield significant clinical clues and should prompt either inpatient or outpatient work-up.
In patients with deep ulcers and concern for critical limb ischemia, inpatient consultation should be sought. In patients with superficial venous or arterial ulcers, referral for outpatient ABI, color duplex ultrasound, or both should be made; most of these patients should also be directly referred to a vascular and/or wound specialist. Patients with more benign forms of disease who endorse chronic symptoms suspicious for mild to moderate PAD or CVI can be seen by a PCP for further management. All patients should be educated about the importance of follow-up as it remains their best chance to curb the progression of disease, reduce the risks for recurrent infection, and improve overall quality of life.
Back to the original case
Our patient’s lower extremity erythema, fever, and leukocytosis improved with 3 days of IV vancomycin treatment. Her wound was kept clean with moist dressings and showed no signs of deep infection; with elevation, her bilateral lower extremity edema also improved. Her physical exam findings and clinical history were highly suspicious for long-standing CVI. She was discharged with oral antibiotics and a referral to wound care for ongoing management of her superficial ulcers. An outpatient venous duplex ultrasound and ABI were scheduled prior to her vascular surgery appointment to effectively rule out PAD before consideration of further therapy for severe CVI.
Dr. Anjali A. Nigalaye
Dr. Nigalaye is an attending physician in the division of hospital medicine at Mount Sinai Beth Israel Hospital in New York, and assistant professor of medicine at the Icahn School of Medicine of Mount Sinai. Dr. Merrill is an attending physician in the division of hospital medicine at Mount Sinai Beth Israel, and assistant professor of medicine at the Icahn School of Medicine at Mount Sinai.
Key Points
- Hospitalists are in a unique position to identify patients with peripheral vascular disease when they are admitted with SSTIs.
- When assessing patients, it is important to consider peripheral arterial disease (PAD) and chronic venous insufficiency (CVI) separately.
- The classic symptom for PAD is claudication. In contrast, symptoms of CVI present more variably.
- Barring cases of critical limb ischemia, the main objective of identifying PAD or CVI is to arrange testing and follow-up after discharge.
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