{"id":4907,"date":"2024-12-25T00:47:00","date_gmt":"2024-12-25T00:47:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=4907"},"modified":"2025-10-01T11:38:23","modified_gmt":"2025-10-01T19:38:23","slug":"usmle-step-2-question-of-the-day-leg-pain","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-leg-pain","title":{"rendered":"USMLE\u00ae Step 2 Question of the Day: Leg pain"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-leg-pain\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-leg-pain\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-leg-pain\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-leg-pain\/#Major_Takeaway\" >Major Takeaway<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-leg-pain\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-leg-pain\/#References\" >References&nbsp;&nbsp;<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Get ready for USMLE Step 2 CK with a question focusing on necrotizing soft tissue infections (NSTI). Can you describe and interpret the diagnostic workup for an adult presenting with an NSTI and identify the key diagnostic features that differentiate between NSTI, possible NSTI, and non-NSTI? Let&#8217;s find out!<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 58-year-old woman presents to the emergency department for evaluation of 2 days of worsening left leg pain, fevers, and fatigue. The patient has a past medical history of IV drug use and reports that she recently injected heroin into her left foot. Temperature is 38\u00b0C (100.4\u00b0F), blood pressure is 132\/60 mmHg, pulse is 104\/min, respiratory rate is 18\/min, and oxygen saturation is 97% on room air. &nbsp;The patient appears uncomfortable. Examination of the left lower extremity reveals erythema over the dorsal foot, induration, and moderate tenderness to palpation. No crepitus is palpated. The patient is started on IV fluids and broad-spectrum antibiotics. Laboratory findings are shown below. CT imaging demonstrates evidence of increased attenuation and stranding of the subcutaneous fat, as well as edema and fluid tracking along the superficial and deep fascia of the calf. &nbsp;Which of the following is the best next step in management?&nbsp;<\/p>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><tbody><tr><td><strong>Laboratory value&nbsp;<\/strong><\/td><td><strong>Result&nbsp;<\/strong><\/td><\/tr><tr><td colspan=\"2\">Serum chemistry&nbsp;<\/td><\/tr><tr><td>Sodium&nbsp;&nbsp;<\/td><td>129 mEq\/L&nbsp;<\/td><\/tr><tr><td>Potassium&nbsp;&nbsp;<\/td><td>4.5 mEq\/L&nbsp;<\/td><\/tr><tr><td>Chloride&nbsp;<\/td><td>&nbsp;97 mEq\/L&nbsp;<\/td><\/tr><tr><td>Creatinine&nbsp;&nbsp;<\/td><td>1.8 mg\/dL&nbsp;<\/td><\/tr><tr><td>HCO3&nbsp;<\/td><td>18 mEq\/L&nbsp;<\/td><\/tr><tr><td>Glucose&nbsp;<\/td><td>343 mg\/dL&nbsp;<\/td><\/tr><tr><td>BUN&nbsp;<\/td><td>25&nbsp;<\/td><\/tr><tr><td colspan=\"2\">CBC&nbsp;<\/td><\/tr><tr><td>Hemoglobin&nbsp;<\/td><td>11.5 &nbsp;g\/dL&nbsp;<\/td><\/tr><tr><td>Leukocyte count&nbsp;<\/td><td>18,100 \/mm3&nbsp;<\/td><\/tr><tr><td>Platelet count&nbsp;<\/td><td>225,000\/mm3&nbsp;<\/td><\/tr><tr><td>Lactic acid&nbsp;<\/td><td>3.6&nbsp;<\/td><\/tr><tr><td>CRP&nbsp;<\/td><td>25 mg\/dL&nbsp;<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Emergent surgical consultation for debridement<br><br>B. Admission to the hospital for continued IV antibiotics<br><br>C. Discharge on cephalexin<br><br>D. Infectious disease consultation<br><br>E. Ultrasonography of the left lower extremity<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><em>Scroll down for the correct answer!<\/em><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Emergent surgical consultation for debridement<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the&nbsp;<strong>Main Explanation<\/strong>, let&#8217;s see why the answer wasn&#8217;t B, C, D, or E. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Today&#8217;s incorrect answers are&#8230;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Admission to the hospital for continued IV antibiotics<br><br>Incorrect:<\/strong>&nbsp;This patient has CT evidence consistent with NSTI and a high LRINEC score and can be diagnosed clinically with an NSTI. The next step in management is emergent surgical consultation for debridement.<br><br><strong>C. Discharge on cephalexin<br><br>Incorrect:<\/strong>&nbsp;This patient has CT evidence consistent with NSTI and a high LRINEC score and can be diagnosed clinically with an NSTI. The next step in management is emergent surgical consultation for debridement.<br><br><strong>D. Infectious disease consultation<br><br>Incorrect:<\/strong>&nbsp; This patient has CT evidence consistent with NSTI and a high LRINEC score and can be diagnosed clinically with an NSTI. The next step in management is emergent surgical consultation for debridement.<br><br><strong>E. Ultrasonography of the left lower extremity<br><br>Incorrect:<\/strong>&nbsp; This patient has CT evidence consistent with NSTI and a high LRINEC score and can be diagnosed clinically with an NSTI. The next step in management is emergent surgical consultation for debridement. An ultrasound is not necessary.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient with a history of injection drug use presents for evaluation of fever, pain, erythema, and induration of the left foot. This patient&#8217;s clinical examination findings are concerning for a necrotizing soft tissue infection; however, no crepitus is palpated, and the patient has moderate and not severe pain, which makes the diagnosis in question.&nbsp;The next step in evaluation is to use the CT findings and LRINEC score to identify the likelihood of NSTI. If, as seen in this patient, the&nbsp;LRINEC is high (&gt;8)&nbsp;or the&nbsp;CT shows findings consistent with NSTI (edema and inflammatory changes in the subcutaneous tissue), then the diagnosis of NSTI can be made clinically, and an&nbsp;emergent surgical consult&nbsp;should be called.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Initial bloodwork for patients with suspected NSTI should include&nbsp;cbc, cmp, lactic acid, blood cultures, inflammatory markers (e.g. crp\/esr), and CK levels.&nbsp;Patients without evidence of crepitus and without rapidly progressing disease on physical examination should have blood cultures drawn, IV antibiotics administered, imaging performed, and the LRINEC should be calculated. Imaging results and the LRINEC score can be used to diagnose NSTI, possible NSTI, or non-necrotizing infections. Patients with crepitus or rapidly progressing physical exam findings require immediate surgical consultation for operative debridement.<\/p>\n\n\n\n<figure class=\"wp-block-image aligncenter is-resized\"><img decoding=\"async\" src=\"https:\/\/osmose-it.s3.amazonaws.com\/tMO5sfvHSQOvcxL7_yx4pa6fQlyl_8Mu\/_.png\" alt=\"LABORATORY RISH INDICATOR FOR NECROTIZING FASCIITIS (LRINEC) SCORE:\nCRP: <15mg\/dL: 0 \/ .15mg\/dL + 4\nWBC (x 10,000\/uL): , 15k: 0 \/ 15-25k: +1 \/ &gt;25k: +2\nHemoglobin (g\/dL): &gt;13.5: 0 \/ 11-13.5: +1 \/ <11: +2\nSodium (mEq\/L): 135: 0 \/ < 135: +2\nCreatinine (mg\/dL): <1.6: 0 \/ &gt;1.6: +2\nGlucose (mg\/dL): <180: 0 \/ &gt;180: 1\nScores =\/&gt; had a PPV of 93.4% for NSTIs.\nScores < 6 were low risk, but not NO risk, for necrotizing soft tissue infections.\" style=\"width:502px;height:auto\"\/><\/figure>\n\n\n\n<figure class=\"wp-block-image aligncenter is-resized\"><img decoding=\"async\" src=\"https:\/\/osmose-it.s3.amazonaws.com\/DIOcMnz3R-CHNRRkZoVkeZTjTXqYl7Ou\/_.png\" alt=\"* Can occur anywhere and lead to:\n- Limb loss\n_ Severe systemic toxicity\n- Death\n*Necrotizing fasciitis associated with highest mortality rate\n* Majority can be diagnosed clinically\n* CT scan and LRINEC score can differentiate: \n- NSTI\n- Possible NSTI\n- Non-necrotizing infections\" style=\"width:502px;height:auto\"\/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Patients with a suspected NSTI but without crepitus or rapidly progressive findings on physical exam should have CT imaging performed and a LRINEC score calculated to assess the likelihood of NSTI and guide management.&nbsp;&nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Watch the Osmosis video: <a href=\"https:\/\/www.osmosis.org\/learn\/Necrotizing_soft_tissue_infections:_Clinical_sciences\">Necrotizing soft tissue infections<\/a>.<\/strong><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References&nbsp;&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Bonne SL, Kadri SS. Evaluation and Management of Necrotizing Soft Tissue Infections. Infect Dis Clin North Am 2017; 31:497.&nbsp;<\/li>\n\n\n\n<li>Hakkarainen TW, Kopari NM, Pham TN, Evans HL. Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg. 2014 Aug. 51 (8):344-62.&nbsp;<\/li>\n\n\n\n<li>Hua C, Urbina T, Bosc R, et al. Necrotising soft-tissue infections. Lancet Infect Dis 2023; 23:e81.&nbsp;<\/li>\n\n\n\n<li>May AK, Stafford RE, Bulger EM, et al. Treatment of complicated skin and soft tissue infections. Surg Infect 2009;10:467\u2013499.&nbsp;<\/li>\n\n\n\n<li>Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front Surg. 2014. 1:36.&nbsp;<\/li>\n\n\n\n<li>Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med 2017; 377:2253.&nbsp;<\/li>\n\n\n\n<li>Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis 2014; 59:147.&nbsp;<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image\"><a href=\"https:\/\/osmosis.org\/create\" target=\"_blank\" rel=\"noreferrer noopener\"><img decoding=\"async\" src=\"https:\/\/osmose-it.s3.amazonaws.com\/QAjRxrSTSrWqy8myI-vHEEFMS9uGh5l7\/_.png\" alt=\"\"\/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em><strong>Want more &nbsp;USMLE\u00ae Step 2 CK practice questions?&nbsp;Try Osmosis by Elsevier today! Access your&nbsp;<a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a>&nbsp;and discover why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Prep for the USMLE\u00ae Step 2 CK exam with this case study that focuses on a 36-year-old woman with acute leg pain. Learn how to recognize the common origins of thrombus and identify appropriate management steps. Dive into the details and sharpen your clinical skills for effective patient care!<\/p>\n","protected":false},"author":202,"featured_media":4908,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[27,5,10,20,34,16,43,1370,45],"tags":[150,440,516,448,84,514,245,279,515,185],"class_list":["post-4907","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-clerkships","category-clinical-skills","category-exam-prep","category-omm","category-do","category-residency","category-step-2-questions","category-step-2","tag-clinical-practice","tag-emergency-medicine","tag-infection-control","tag-medical-diagnosis","tag-medical-education","tag-nsti","tag-nursing-education","tag-patient-assessment","tag-surgical-management","tag-usmle"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 2 Question of the Day: Leg pain - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-leg-pain\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 2 Question of the Day: Leg pain - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"Prep for the USMLE\u00ae Step 2 CK exam with this case study that focuses on a 36-year-old woman with acute leg pain. 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