Quick answer
How should I present a suspected necrotizing fasciitis case on rounds?
Lead with pain out of proportion to the exam and the rapidly spreading skin changes, since these are the classic red flags. Give vitals showing septic physiology and the severity labs before naming necrotizing fasciitis. End with emergent surgical exploration and broad-spectrum antibiotics, stating clearly that surgery is not delayed for imaging.
Before you speak
Define the moment and the information you actually have
An emergency-department presentation immediately after severity labs return, before any imaging has been obtained.
The emergency, surgical, and ICU teams deciding on emergent operative exploration.
History, vital signs, a skin exam, severity labs including white cell count, lactate, sodium, creatinine, and glucose, and an initial plain radiograph already showing soft tissue gas. Formal cross-sectional imaging and the operative extent of necrosis are not part of this simulation.
About 85 seconds
Fictional training case: The presentation is locked to the simulated patient JSON. It names important unknowns instead of inventing an examination, vital signs, allergies, or tests.
Complete spoken example
First, read it once without stopping
The paragraph breaks show the clinical shape. In a real presentation, pause briefly between ideas rather than announcing the headings.
Mr. Perez is a 55-year-old man with type 2 diabetes who presents with rapidly spreading dusky purple skin changes on his leg, with pain severely out of proportion to the exam and palpable crepitus.
The redness and discoloration have advanced rapidly over hours, with hemorrhagic blisters and excruciating pain, and he is worried about serious complications and a prolonged illness.
He has type 2 diabetes, hypertension, and mild dyslipidemia, and takes metformin and lisinopril; he is employed full-time and drinks socially.
His vitals show a fever of 38.7 — in the 38-to-39 range — heart rate 128, blood pressure 92 over 58, respiratory rate 24, and oxygen saturation 94% on room air, consistent with septic physiology. His white blood cell count is markedly elevated at 22,000 with a left shift, hemoglobin is 10.8, sodium is low at 131, creatinine is elevated at 1.9, glucose is markedly elevated at 310, and lactate is elevated at 4.2. CRP is over 150, giving a LRINEC score of at least 8, high risk for necrotizing fasciitis, and a plain radiograph already shows soft tissue gas tracking along the fascial planes.
My diagnosis is necrotizing fasciitis of the leg with septic shock in a patient with poorly controlled diabetes, based on the pain out of proportion, rapid progression, crepitus, and the severity labs together.
I am obtaining emergent surgical consultation for immediate operative exploration and debridement without delaying for imaging, starting broad-spectrum IV antibiotics covering gram-positive, gram-negative, and anaerobic organisms now, and beginning aggressive fluid resuscitation and vasopressor support for septic shock with strict glycemic control.
Build the presentation
Give every sentence one job
A presentation is a compressed clinical argument, not a chart read aloud. These six moves keep the facts connected to your reasoning.
Opening one-liner
Name pain out of proportion and the skin changes together
“Mr. Perez is a 55-year-old man with type 2 diabetes who presents with rapidly spreading dusky purple skin changes on his leg, with pain severely out of proportion to the exam and palpable crepitus.”
Why it belongs: Pain out of proportion to the visible findings and crepitus are the classic red flags that should trigger emergency surgical evaluation rather than treatment for simple cellulitis.
This is a diabetic man with a bad leg infection.
He has rapidly spreading dusky purple skin changes with pain out of proportion to the exam and palpable crepitus.
Why: Naming the specific red-flag findings is far more urgent-sounding than a general description of infection.
History of present illness
Give the speed of progression
“The redness and discoloration have advanced rapidly over hours, with hemorrhagic blisters and excruciating pain, and he is worried about serious complications and a prolonged illness.”
Why it belongs: The specific speed of progression, measured in hours rather than days, is what distinguishes this from ordinary cellulitis and should be stated explicitly.
The infection is spreading and hurts a lot.
The skin changes have advanced rapidly over hours, with hemorrhagic blisters and pain out of proportion to the exam.
Why: Naming the timeframe in hours conveys the urgency more precisely than 'spreading.'
Relevant background
Name the risk factors that predispose to this severity
“He has type 2 diabetes, hypertension, and mild dyslipidemia, and takes metformin and lisinopril; he is employed full-time and drinks socially.”
Why it belongs: Diabetes is a recognized risk factor for necrotizing soft-tissue infection and for a more severe course, and this history explains part of why his presentation is this dramatic.
He has diabetes and high blood pressure.
He has type 2 diabetes, a recognized risk factor for necrotizing soft-tissue infection and a more severe course.
Why: Connecting the diabetes to its specific relevance is more useful than listing it as a passing detail.
Objective data
State vitals and the severity labs
“His vitals show a fever of 38.7 — in the 38-to-39 range — heart rate 128, blood pressure 92 over 58, respiratory rate 24, and oxygen saturation 94% on room air, consistent with septic physiology. His white blood cell count is markedly elevated at 22,000 with a left shift, hemoglobin is 10.8, sodium is low at 131, creatinine is elevated at 1.9, glucose is markedly elevated at 310, and lactate is elevated at 4.2. CRP is over 150, giving a LRINEC score of at least 8, high risk for necrotizing fasciitis, and a plain radiograph already shows soft tissue gas tracking along the fascial planes.”
Why it belongs: The hypotension and tachycardia confirm septic shock is already present, and the elevated white count, lactate, low sodium, and elevated creatinine together support a high-risk severity score that mandates emergent surgery.
His vitals and labs are all abnormal.
His blood pressure is 92 over 58 with a lactate of 4.2, white count of 22.0, and sodium of 131, consistent with septic shock and a high-risk severity picture.
Why: Exact values let the surgical and ICU teams judge severity immediately rather than accepting a vague summary.
Assessment
Commit to the diagnosis as a surgical emergency
“My diagnosis is necrotizing fasciitis of the leg with septic shock in a patient with poorly controlled diabetes, based on the pain out of proportion, rapid progression, crepitus, and the severity labs together.”
Why it belongs: Naming this explicitly as a surgical emergency, not just a severe skin infection, is what should prompt immediate operative involvement rather than escalating antibiotics alone.
This is a severe skin infection.
This is necrotizing fasciitis with septic shock, a surgical emergency requiring immediate operative evaluation.
Why: Naming the specific diagnosis and its emergency status is what should drive the team's next action.
Plan
State that surgery is emergent and not delayed for imaging
“I am obtaining emergent surgical consultation for immediate operative exploration and debridement without delaying for imaging, starting broad-spectrum IV antibiotics covering gram-positive, gram-negative, and anaerobic organisms now, and beginning aggressive fluid resuscitation and vasopressor support for septic shock with strict glycemic control.”
Why it belongs: Stating explicitly that surgery is not delayed for imaging directly addresses the most dangerous and common error in this diagnosis, where confirmatory imaging can waste critical time.
I'll start antibiotics and maybe get imaging first.
I am obtaining emergent surgical consultation now, without delaying for imaging, and starting broad-spectrum antibiotics and resuscitation immediately.
Why: Stating that imaging is not awaited directly corrects the most dangerous error in managing this diagnosis.
Do not fill the blanks
Say what has not yet been established
Real presentations often happen before the chart is complete. A brief, explicit limitation is safer and more credible than a polished invention.
Formal cross-sectional imaging and operative extent of necrosis
Say: “A plain radiograph already shows fascial gas, but formal cross-sectional imaging and the true extent of necrosis are not part of this simulation; clinical findings and severity labs are guiding the emergency decision, and the actual extent will be defined at surgery, not by further imaging.”
Waiting for cross-sectional imaging would delay surgery that is already clinically indicated; the plain radiograph finding supports that decision but does not replace surgical exploration.
Blood culture and wound culture results
Say: “Blood and wound culture results are not yet available in this simulation and will guide narrowing the antibiotic regimen once the organism is identified.”
Empiric broad-spectrum coverage continues until culture results allow safe narrowing.
Clinical compression
What leads, what stays, and what can wait?
| Source detail | Decision | Reason |
|---|---|---|
| Rapidly spreading dusky purple skin changes with pain out of proportion | Lead | These are the classic red flags that separate this from ordinary cellulitis. |
| Palpable crepitus and hemorrhagic blisters | Lead | These specific exam findings are highly concerning and support urgent surgical evaluation. |
| Employed full-time, social drinker | Omit | This detail does not change the emergency surgical decision. |
| Poorly controlled diabetes with glucose of 310 | Include | It is both a risk factor for this severity and a factor that changes glycemic-control management. |
| Lactate of 4.2 and sodium of 131 | Lead | These are components of the severity score that support the urgency of the surgical decision. |
After the presentation
Likely attending questions
Answer the question first, then give the evidence. If the source case does not contain the answer, say what you would verify.
How is this different from simple cellulitis?
Simple cellulitis is typically less painful relative to its appearance and progresses more slowly; pain grossly out of proportion to the exam, rapid progression over hours, crepitus, and hemorrhagic bullae all point toward necrotizing fasciitis instead, which needs emergent surgical exploration rather than antibiotics alone.
Why not wait for a CT scan to confirm the diagnosis first?
Imaging can delay the surgery that is already clinically indicated, and any delay in debridement is associated with worse outcomes in necrotizing fasciitis; the diagnosis here is made clinically and supported by the severity labs, not by imaging.
Why use three different antibiotics together?
Broad empiric coverage addresses gram-positive, gram-negative, and anaerobic organisms because the infection can be polymicrobial or caused by a single toxin-producing organism, and one of the agents also has an antitoxin effect relevant to certain streptococcal infections.
Self-check
A 30-second check before you present
- Name pain out of proportion to the exam in the opening sentence.
- State the speed of progression in hours, not just 'spreading.'
- Name crepitus and hemorrhagic bullae as specific red-flag findings.
- State vitals to confirm whether septic shock is already present.
- Give the severity labs with exact values, including lactate and sodium.
- State explicitly that surgery is not delayed for imaging.
- Name the broad-spectrum antibiotic rationale.
- State that cultures are pending and will guide narrowing therapy.
Common presentation problems
Repair the habits that make a case hard to follow
Calling this 'a severe cellulitis' without naming the red flags
Repair: State the specific findings—pain out of proportion, crepitus, and rapid progression—that separate it from cellulitis.
Waiting for imaging before consulting surgery
Repair: State that surgical consultation and exploration happen now, without delay for imaging.
Naming only one antibiotic when broad coverage is needed
Repair: State the full broad-spectrum regimen and its rationale.
Treating glucose control as a lower priority
Repair: State that strict glycemic control is part of the resuscitation plan given his diabetes.
Frequently asked questions
Oral case presentation questions
Do I need to mention the LRINEC score by name?
Yes, if your program uses it, since it formalizes the severity assessment from these exact labs; otherwise, stating the individual values and their concerning pattern is sufficient.
Should I mention IVIG?
You can mention that it would be considered if streptococcal toxic shock syndrome is suspected, without committing to it as part of the immediate emergency plan unless that specific picture develops.
How long should this presentation be?
This worked example targets about 85 seconds. A patient in florid septic shock would need an even faster initial alert focused on vitals and the need for immediate surgery.
Practice out loud
Turn the patient encounter into your own presentation
Bedside English lets you interview an AI patient, then practice presenting the collected case to an AI attending and respond to follow-up questions.
Editorial record
Sources, provenance, and review boundary
The patient facts come from simulated case id_008. Clinical framing and presentation design were checked against the sources below. This page teaches clinical communication and reasoning; it is not medical advice or a local protocol.
- Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 UpdateInfectious Diseases Society of America · accessed 2026-09-03
- Feedback on Oral Presentations during RoundsStanford Medicine · accessed 2026-09-03
- Clinical Teaching Tools: OMP and SNAPPSUCSF Medical Education · accessed 2026-09-03
Published: · Last source, safety, and language review: