MEDICAL BACKGROUND
NECROTIZING FASCIITIS
TABLE OF CONTENTS
01
Introduction/Definition
02
Etilogy
03
Epidemiology
04
APK
05
Pathophysiology
06
Diagnosis
TABLE OF CONTENTS
07
Differential Diagnosis
08
Test and measures
09
Treatment/Management
10
PT Treatment
01
Introduction/Definition
Necrotizing fasciitis (NF) is a life-threatening bacterial infection causing necrosis of
the fascia, underlying skin, and vasculature.
It is commonly known as a "flesh-eating disease"
Group A Streptococci are thought to be the most common organisms causing
necrotizing fasciitis
Hallmarks:
Friable superficial fascia
Gray exudates pus
Widespread tissue destruction
Note: Infection is either pollumicrobial or monomicrobial
Presentation:
Severe pain
Erythematous, blistering, and necrotic skin
Systemically unwell, fever and tachycardia
Presence of crepitus
02
Etiology
Rare but rapidly progressive, life-threatening bacterial infections that can
destroy the epidermis, dermis, subcutaneous tissue, fascia, and muscle.
It can be caused by polymicrobial such as the group A Streptococcus (GAS)
and Staphylococcus aureus
Clostridium, Vibrio, and Klebsiella (other bacterias)
Classification of NF:
1. Type 1: NF caused by both aerobic and anaerobic bacteria
2. Type 2: NF caused by group A beta-hemolytic Streptococcus and
Staphylococcus aureus.
3. Type 3: NF caused by clostridium perfringens or less commonly
clostridia septicum. It usually follows SignifIcant injury or surgery
and results in gas under the skin (crackling).
03
Epidemiology
The incidence of NF is estimated to be 0.3 to 15 cases per 100,000 population.
50% of cases occur in previously healthy individuals
Risk Factors
Abdominal surgery
Medical comorbidities (e.g. diabetes, malignancy)
More than 70% of cases are recorded in people with at least one of these clinical
situations: immunosuppression, diabetes, alcoholism/drug abuse/smoking,
malignancies, and chronic systemic diseases. For unclear reasons, it occasionally
occurs in people with an apparently normal general condition.
04
APK
The Skin
1. The body's largest and primary
protective organ.
2. Functions as a temperature regulator
and protection against ultraviolet (UV)
light,
trauma,
pathogens,
microorganisms, and toxins.
3. Immunologic surveillance, sensory
perception, control of insensible fluid
loss, and homeostasis in general.
1. Epidermis
Stratum Corneum
Stratum Lucidum
Stratum Granulosum
Stratum Spinosum
Stratum Basale
2. Dermis
Papillary Layers
Reticular layer
3. Hypodermis
(deeper subcutaneous tissue)
Fascia
made up of sheets of connective tissue that are
found below the skin. These tissues attach, stabilize,
impart strength, maintain vessel patency, separate
muscles, and enclose different organs.
Traditionally, the word fascia was used primarily by
surgeons to describe the dissectible tissue seen in
the body encasing other organs, muscles, and
bones. Recently, the definition has been broadened
to include all collagenous-based soft tissues in the
body, including cells that create and maintain the
extracellular matrix.
Fascia
Classification of Fascia:
1. Superficial fascia
2. Deep fascia
3. Visceral fascia
4. Parietal Fascia
05
Pathophysiology
CLINICAL MANIFESTATION:
Early features – pain, erythema, and edema
Late features such as – pyrexial, tachycardia, hypotension,
tachypnea, and altered mental status
X-ray may show soft tissue gas
06
Diagnosis
DIAGNOSIS:
1. Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC)
DIAGNOSIS:
2. Plain Radiography
3. Computed tomography (CT Scan)/Magnetic Resonance Imaging
(MRI)
07
Differential
Diagnosis
DIFFERENTIAL DIAGNOSIS:
1. Synergistic Necrotizing Cellulitis
2. Streptococcal Myonecrosis
3. Gas Gangrene
08
Test and measures
Test and measures
1. Wound assessment
2. Integumentary Integrity
3. Observation and palpation assessment
4. Color assessment
5. Drainage assessment
6. Stage of current wound assessment
7. Wound healing tools
8. Sensory assessment
9. Range of motion assessment
09
Treatment/Management
Treatment/Management
1. Antibiotic treatment
2. Hyperbaric oxygen therapy (HBOT)
3. Intravenous immunoglobulin (IVIG)
4. Wound closure and reconstructive surgeries are performed once
bacteriologic, metabolic, and nutritional balances are obtained.
5. AB103: One study assessed the efficacy of a new type of treatment that affects
the immune response, called AB103.
6. Supportive therapy
Treatment/Management
Urgent referral for extensive surgical debridement
Aggressive wound debridement should be performed early with broadspectrum intravenous antibiotics unless a monomicrobial agent is identified,
in which case more directed therapy would be appropriate.
supportive care and resuscitation
10
PT Treatment
Physiotherapy management
Physiotherapy management will primarily occur after surgical debridement
and mainly focus on the maintenance, prevention, and management of
secondary complications.
Physiotherapy does not play a role in the curative management of this
pathology. Patients with necrotizing fasciitis have an increased risk of loss of
endurance and strength.
Prevention:
Prophylactic chest physiotherapy to prevent atelectasis, as these patients
often spend most of their time in bed
Loss of muscle power and range of motion: By incorporating an exercise
program
Loss of function: Mobility program
Pressure sores: Positioning and mobilization
INITIAL EVALUATION
GENERAL INFORMATION:
Patients Name: MEP
Age: 46
Sex: Female
Address: Dulao, Aringao, La Union
Civil Status: Married
Handedness: Right
Occupation: Housewife
Religion: Roman Catholic
GENERAL INFORMATION:
Referring Department: Internal Medicine
Referring Doctor: Brylle Domerson M. Turalba, MD
Rehab Doctor:
Date of Referral: April 11, 2023
Date of Consultation: April 11, 2023
Date of IE: April 11, 2023
Diagnosis: Necrotizing fasciitis lateral neck pulmonary infection 2° PTB
01
SUBJECTIVE
SUBJECTIVE
C/C: Pt’s husband complains of pt general weakness.
Pt‘s Goal: Pt’s husband wants Pt to be able to regain normal strength and optimal function.
HISTORY OF PRESENT ILLNESS
Pt’s present condition started ~ 9 wks PTIE when pt noticed a small mass on the posterior part of the (R) ear. The mass is
not visible but claims to be palpable.
~ 8 weeks PTIE, the mass becomes marble size, palpable and visible associated c tolerable pain and undocumented fever.
Pt sought to consult at a private clinic and was prescribed unrecalled antibiotics. However, pt did not purchase the said
medications and opted to consult a faith healer instead. Pt was instructed by the faith healer to apply coconut oil and
pressure on the affected part.
HISTORY OF PRESENT ILLNESS
After several days, pt noticed the increasing size of the mass accompanied by worsening pain and more
frequent episodes of fever. Mass is ruptured c purulent and blood discharge. Pt has been experiencing body
weakness and DOB, hence pt opted to consult ITRMC. Pt was then admitted after.
On April 11, 2023, pt was referred to the Department of Physical Therapy and rehabilitation medicine for
further evaluation and management of the pt’s condition.
PRESENT MEDICATIONS
DRUG
DOSES
INDICATION
SIDE EFFECTS
Sultamicillin
750mg per tab
b.i.d every 12
hours
Respiratory tract, skin
and soft tissues
infections
Diarrhea, nausea, vomiting,
abdominal pain, sore mouth,
fatigue, and itching.
Relieve pain, tenderness,
swelling, and stiffness
Cough, fever, skin rash,
sneezing, sore throat, swelling
of the face, fingers, feet, or
lower legs.
To treat Gingivitis
Hives, severe skin rash;
wheezing, cold sweats, feeling
light-headed; swelling of your
face
Celecoxib
Chlorhexidine
Gluconate
Mouthwash
200mg per cab
b.i.d
10ml per gargle
t.i.d
PAST MEDICAL HISTORY
PAST MEDICAL HISTORY:
(+) DM II (2012)
(+) Previous Surgery
(-) Hypertension
(-) CVD
(-) Pulmonary Tuberculosis
(-) Allergies
FAMILY HISTORY
PERSONAL HISTORY
Px is a non-smoker
Px is a non-alcoholic
Px drinks coffee occasionally
Px does household chores
SOCIAL HISTORY
Px has (1) son
Px’s family is financially unstable
Px’s husband is a fisherman
ENVIRONMENTAL HISTORY
Px lives in a bungalow house with her husband and son
Px approximately has:
10 steps from Bedroom to Bathroom
8 steps from Bedroom to Livingroom
8 steps from Bedroom to Kitchen
12 steps from the Bedroom to the Main door
Px needs to go up 3 flights of stairs to proceed to the main road
Px commutes with a tricycle and jeepney whenever she goes to
the town proper or to buy groceries
02
OBJECTIVE
VITAL SIGNS
VS:
Ⓝ
ā
p̄
BP (mmHg)
<120/80
130/80
130/80
SPO2 (%)
95-100
92%
94%
OCULAR INSPECTION
Mesomorph
Bedridden
Not in apparent pain/distress
(+) NGT
(+) IV line on (L) dorsal hand and (R) dorsal oot
(+) IFC
(+) Swelling on (L) UE
(+) Dry wound on (L) lateral wrist
(+) General dry scaling of the skin
(-) Deformities
PALPATION
Normothermic on all assessed body parts.
(+) Grade 1 edema on (L) UE
(-) Tenderness
RANGE OF MOTION
All major jts of (B) UE/LE are found to be WNL and were assessed actively and passively done,
with normal end feel except:
Findings: LOM on (B) SH flexion, abduction, and hip flexion.
Significance: pt’s LOM is d/t prolonged immobilization and hospitalization
GROSS MANUAL MUSCLE TEST
All major muscles of (B) UE are graded 2-/5 to 2+/5, while (B)
LE are grossly graded 1/5.
Findings: This indicates muscle weakness on (B) UE/LE
Significance: pt is 2° probable nerve damage and general body
deconditioning.
SENSORY ASSESSMENT
Superficial Sensation:
(3 trials were done grossly for both light touch and pain
sensations. For Light Touch, the dull end of the neuro
hammer and a brush is used, for Pain, the pointy end of the
neuro hammer, )
SENSORY ASSESSMENT
Findings: Pt has intact sensation on all assessed segments. However,
pt’s sensation is decreased in all assessed segments specifically on LE.
Significance: Pt has no sensory deficit that could affect the tx. The intact
sensation was crucial to identify any stimulus that could cause pain
and any possible accident. Also, good sensory input was manifested
thus, pt will able to have smooth and coordinated movements. A fair
superficial sensation will serve as a precaution for the application of
modalities.
DEEP TENDON REFLEX
DEEP TENDON REFLEX
Significance: Pt has normoreflexia on (B) brachialis which indicates the reflex arc
is intact. On (B) biceps and triceps reflex, pt presents a slight but definitely
present response. On (B) LE, pt has hyporeflexia, indicating that the reflex arc has
been damaged or severed.
PATHOLOGICAL REFLEXES
(-) Babinski on (B) foot
(-) Clonus on (B) foot
Significance: There were no pathological reflexes present
that could be a hindrance to pt.’s treatment course and
there would be no unwanted, involuntary movements of
the foot even c the slightest of stimuli.
CHEST AUSCULTATION
Anterior
Normal areas
↓ breath sound in all assessed
Significance: pt’s
diagnosis.
Posterior
N/A
↓ breath sound is d/t secondary complication of pt’s
SPUTUM ASSESSMENT
Findings:
Color: Clear
Odor: Odorless
Amount: > 2 tbsp
Texture: Smooth/non-viscous
Significance: Clear sputum indicates that there is no significant presence of
infection or inflammation in the respiratory tract. Odorless sputum suggests that
there is no significant bacterial or fungal infection present. Non-viscous sputum is
also a positive sign, as overly thick or sticky sputum can indicate that the body is
having difficulty clearing mucus from the lungs.
WOUND ASSESSMENT
Findings:
Size: 2 inches in length. Covering the posterior nape.
Color: Yellowish and black
Odor: Foul
Significance: Pt’s wound extends to the nape. Pt’s wound has a yellowish color
which may indicate the presence of pus or dead tissue in the wound. This could
be a sign of infection or a non-healing wound. Pt also presents black or dark
brown skin surrounding a wound could indicate dead tissue or necrosis. This
can be a sign of a serious wound that requires medical attention.
ACTIVITIES OF DAILY LIVING ASSESSMENT
Barthel Index for Activities of Daily Living (ADL)
Findings: Pt garnered a score of 0 points which indicates pt totally dependent on all ADLs.
Feeding —> 0 = Unable
Bathing —> 0 = Unable
Grooming —> 0 = Unable
Dressing —> 0 = Unable
Bowel control —> 0 = Incontinent (or needs to be given enemas)
Bladder control —> 0 = Incontinent (catheterized, unable to manage alone)
ACTIVITIES OF DAILY LIVING ASSESSMENT
Toilet use —> 0 = Unable
Transfers (bed to chair and back) —> 0 = Unable
Mobility on level surfaces —> 0 = Immobile or <50 yards
Stairs —> 0 = Unable
Significance: Pt being totally dependent in ADLs may be at increased risk of developing
physical health problems, such as pressure ulcers, infections, and falls. Caregiver
education should be emphasized to assist pt in ADLs.
03
ASSESSMENT
PT DIAGNOSIS
Pt is medically diagnosed with Necrotizing fasciitis on lateral neck pulmonary infection 2° PTB as
manifested by a wound 2 inches in length, covering the posterior nape with a yellowish and black
color and a foul smell. Muscle weakness on (B) UE (2-/5 to 2/5) LE (1/5), LOM on (B) SH flexor, abd,
and Hip flexors, total dependence in ADLs, decreased sensation on UE/LE, grade 1+ of bicep and
tricep reflex and grade 0 on the knee and Achilles reflex.
PT DIAGNOSIS
Based on the aforementioned signs and symptoms above, the pt presents, sudden body weakness
followed by DTR on (B) LE. This may be a suggestive diagnosis of GBS. However, it is possible
that necrotizing fasciitis can cause body weakness in rare cases but it is not always present. The
body's immune response to this infection can lead to systemic symptoms such as fever, chills, and
body aches, which can contribute to weakness and fatigue.
↓
PROBLEM LIST
1. Muscle weakness on (B) UE (2-/5 to 2/5) LE (1/5)
2. LOM on (B) SH flexor, abd, and Hip flexors
3. Total dependence on ADLs.
4. Decreased sensation on UE/LE.
LONG-TERM GOALS
1. Pt will be able to achieve optimal muscle strength on
(B) UE/LE s interference to ADLs.
2. Pt will be able to achieve optimal ROM in (B) UE/LE
3. Pt will be able to attain an optimal level of
independence in ADLs, c or s signs of difficulty.
4. Pt will be able to prevent 2° complications, such as jt.
contractures and pressure sores.
SHORT-TERM GOALS
1. Pt will present an increase in muscle strength by 1
muscle grade increment on (B) UE/LE p PT for 6 wks.
2. Pt will present increased ROM on (B) UE/LE by 10-15° of
increments in joint motion p PT for 3 wks.
3. Pt will be able to do ADLs with maximal dependence on
the pt’s husband and other caregivers.
04
PLAN OF CARE
PHYSICAL THERAPY MANAGEMENT
1. AAROMEs on (L) UE x AP x 10 reps x 1 set
2. PROMEs to AAROMEs on (B) LE x AP x 10 reps x 1 set
3. FES on (B) elbow and wrist flexor/extensor
4. ES on (B) knee and ankle flexor/extensor x 5 mins
5. DBE
HOME INSTRUCTION PROGRAM
1. AAROMEs on (L) UE x AP x 10 reps x 1 set
2. PROMEs to AAROMEs on (B) LE x AP x 10 reps x 1 set
3. Proper bed positioning every hour
4. DPE
5. ES (B)UE/LE
RECOMMENDATIONS
1. Respectfully recommend pt to a neurologist.
2. Respectfully recommend the next PT intern to assess the following:
Tactile fremitus
Chest expansion measurement
Chest breathing symmetry
PREPARED BY
Anab M. Alnow
LC PT INTERN 23’
Peter Gabriel Jacinto
UB PT INTERN 23’
Princess Shakira M. Cajigal
MMSU PT INTERN 23’
Jiggy Allen C. Vives
MMSU PT INTERN 23’