Notes on Practice: A First Impression Can Be Deceiving

History
   Ms. P was a 64-year-old obese woman with a history of chronic airway obstruction, chronic obstructive pulmonary disease, congestive heart failure, deep vein thrombosis (DVT), depression, and renal insufficiency. She frequently complained of nausea, which was relieved with over-the-counter medications. She was nonambulatory but able to transfer with assistance to a wheelchair, propel her chair, and perform some of her activities of daily living (ADLs). She was admitted to the skilled nursing facility in June 1998 immediately following a hospitalization for cellulitis of the foot for short-term rehabilitation. Discharge to the home of one of her children where she had been residing prior to hospitalization was anticipated.

   Ms. P actively participated in physical therapy and occupational therapy, working on improving her strength, balance, transferring skills, and ADLs. About 1 month after admission, Ms. P began complaining of pain in her right lower extremity. She was referred to a vascular surgeon. Doppler studies were positive for DVT. Warm soaks, bed rest, and warfarin sodium (Coumadin, DuPont Pharma, Wilmington, Del.), 7.5 mg daily, were ordered. She had an international normalized ratio (INR) of blood clotting factors of 1.5. For the next several weeks, Ms. P was managed at a skilled nursing facility, with varying doses of warfarin sodium depending on her INR.

   In August, a contrast venography was positive for a left common femoral DVT. Warfarin sodium therapy continued. By mid-August, Ms. P began complaining of bilateral leg pain with swelling and redness noted in both extremities. Warm soaks continued and antibiotics were initiated. Bilateral pedal pulses were palpable. By the end of August, ecchymotic areas were noted on both of Ms. P's legs. Leg pain continued. Pain management was attempted with oxycodone and acetaminophen tablets (Percocet, Endo Pharmaceuticals, Inc., Chadds Ford, Pa.) and hydrocodone bitartrate and acetaminophen tablets (Vicodin, Knoll Laboratories, Mount Olive, NJ) with moderate effect.

Wound Description
   By mid-September, open areas were noted on Ms. P's right thigh - one on top of her thigh, one on her inner thigh, and several on her right knee (see Figures 1, 2, and 3). All of the wounds began as red ecchymotic areas, rapidly progressing to purple, then opening up with yellow sloughy bases, large amounts of serous drainage, and reddened perimeters. Moist wound healing protocols were initiated. Wounds were indurated and painful. The physician on staff at the skilled nursing facility was closely following Ms. P. Her warfarin sodium therapy continued for the treatment of the DVTs.

   By early October, it became obvious that wounds were not responding to standard wound care and, in fact, were worsening. In addition, several other areas had opened under Ms. P?s pannus. She was admitted to the university hospital on October 14 for treatment of her DVT and evaluation of the wounds.

Diagnosis
   While at the university hospital, Ms. P was seen by a hematologist. The results of an anti-thrombin III test revealed a decreased level of anti-thrombin indicative of increased thrombotic tendency. A protein C test, performed on people with severe thrombosis or predisposed to thrombosis, showed decreased levels. This test led to the diagnosis of Coumadin-induced skin necrosis.

 Management
   Coumadin therapy was discontinued. Enoxaparin sodium (Lovenox, Rhone-Poulenc Rorer Pharmaceuticals, Inc., Collegeville, Pa.) was initiated subcutaneously to manage the DVTs. Ms. P was discharged back to the skilled nursing facility from the hospital on October 22 with the added diagnosis of Coumadin-induced skin necrosis.

   Wounds were surgically debrided and treated with standard moist wound healing protocols. The wounds began responding in a predictable manner. Pain with dressing changes decreased until Ms. P was pain free. By March 1999, all wounds were 100% epithelialized.

   Ms. P continued to work in physical therapy on her ability to transfer and in occupational therapy on independently completing her ADLs. By May 1999, she was safely discharged to her family's home.