Boards 2 Clinical

Systemic – DMII, PE, Lupus, MS, RA, COPD, Alcohol abuse
Dermatological – Malignant melanoma, Ulcer, verruca, Tinea, onychomycosis
Vasculature – PAD, Venous insufficiency, Sickle Cell
Musculature – Ankle fracture, Hammertoe, HAV, Pes planus, Pes cavus, PTTD, Charcot, Stress fracture, Plantar Fasciitis, Lisfranc fracture
Neurological – Morton’s Neuroma, Tarsal tunnel

TOP 10

1.Malignant Melanoma

S: Dark or discolored skin spot or mole. New never seen before, growing in size. No pain or redness associated. Check family history of skin cancers

O: ABCDE: asymmetry, border irregular, color change, diameter, evolving. (-)spots or lesions in other areas of body. (-)callus, edema, erythema, blister, or eschar.

A: Differential diagnosis:

  1. Acral Lentiginous Melanoma
  2. Suerficial spreading melanoma
  3. lentigo melaoma
  4. Squamous cell carcinoma
  5. Dysplastic Nevi

P: 

  • excisional biopsy (punch biopsy)
  • surgical biopsy
  • sentinel node biopsy, to check if melanoma has spread to lymph nodes
  • refer to primary care doctor
  • refer to dermatology

2.Plantar Fasciitis

S: Sharp shooting pain, pain first step in the morning, gets better over time. Tightening at the bottom of their heel. Unable to tolerate high heels or flats. Mild swelling and redness. Inappropriate shoe gear. No history of trauma.

O: Pain upon palpation of medial tubercle, pain along medial and/or plantar fascia. Obesity, equinus, fat-pad atrophy. (-) heel squeeze test for fracture. (+) Windlass mechanism. (-) Tinel sign.

A: Differential diagnosis:

  1. Plantar Fasciitis
  2. Tarsal tunnel syndrome
  3. Baxter’s neuritis
  4. Calcaneal cysts
  5. Calcaneal stress fracture

P:

  • Radiographs
  • MRI
  • Ultrasound
  • Rest, Ice, Compression, Elevate
  • Physical Therapy
  • NSAIDS
  • Cortisone injection
  • Custom orthotics, inserts
  • Surgery: Topaz, plantar fasciotomy, heel spur excision

3.DVT

S: History of smoking, MI, CHF, trauma, immobilization, post-surgery. Calf pain, possible chest pain, shortness of breath. Concern for pulmonary embolism!

O: Red, hot, swollen leg. Pain near calf. Slight fever and shortness of breath. Painful swollen leg. (+) Homan’s sign.

A: Differential Diagnosis:

  1. Deep Vein Thrombosis (DVT)
  2. Venous Insufficiency
  3. Lymphedema
  4. Lymphangitis
  5. Cellulitis

P:

  • Ultrasound
  • D-dimer exam
  • Venography (gold standard)
  • Medications: Heparin, Levonox, Warfarin
  • Compression stockings
  • Surgery: consult vascular
  • Rule-out PE: ECG, CT

4.Pre-op exam

S: A 27 year old female presents for pre-operative examination for bunionectomy surgery. Denies any fevers chills nausea or vomiting. Denies any illnesses, denies taking any medications, denies any allergies. Denies previous surgery.

O:

  • General: no abnormalities
  • Cardiovascular: auscultation revealed regular rate and rhythm S1, S2
  • Pulmonary: lungs clear to auscultation bilaterally
  • Abdomen: soft, non distended, no pain upon palpation of liver or spleen
  • Extremities: no swelling, no varicosites
  • Skin/wound: no wounds

A: A healthy 27 year old female cleared for in office physical exam for pre-surgery checklist. Labs and tests pending before surgery date.

P:

  • Order labs: CBC, BMP, PT/INR
  • Order ECG, Radiographs, Urine analyses, Pregnancy Test
  • Radiographs reviewed for etiology and surgical intervention
  • Date determined once cleared by anesthesia

 

5.Lisfranc fracture

S: Motor vehicle accident, fall from height, wrong step on curve, heavy object fell on foot. Signs of swelling, redness. Patient walks with a limp, complains of sensitive pain to midfoot. Check for skin openings. Denies any fevers, chills, nausea or vomiting.

O: Inability to bear weight, tenderness upon palpation, ecchymosis on dorsal or plantar aspect. (-)anterior tibial artery severence. (-)Compartment syndrome.

Radiograph: AP view shows fracture, dislocation, Fleck sign, increase in space between 1st and 2nd base. Lateral view shows 2nd met base to be higher (step-off).

A: Differential Diagnosis:

  1. Lisfranc fracture
  2. Metatarsal base fracture
  3. Navicular fracture
  4. Compartment syndrome
  5. Nerve contusion, from direct trauma

P:

  • Check neuro and vascular supply
  • Radiographs and/or CT for surgical consideration
  • NWB posterior splint in 6 weeks
  • Pain control with NSAIDS or Tramadol
  • Consider open reduction- internal fixation (ORIF)

6.Bunion

S: Pain on medial 1st MTPJ with associated redness, swelling, thickening of skin. Big toe overlapping second toe. Painful when wearing closed toed shoes, heels, or barefooted.

Family history: arthritis

O: (+)Equinus Gastroc vs soleus. Hallux range of motion diminished, reducible, tracking vs track bound. (+) hypermobile 1st ray, increased Root test. Pain upon palpation of medial 1st MTPJ. (-)sesmoiditis, callus, cellulitus. (-)Tinel or Valleix nerve sign. Full examination includes WB examination – diminished Hubcher maneuver, diminished windlass mechanism.

Radiographs: increase HAV, IMA, PASA, DASA

A: Differential Diagnosis:

  1. Hallux Abducto Valgus (dorsal-medial eminence)
  2. Hallux limitus or rigidus (dorsal eminence)
  3. Gout
  4. Bursitis

P:

  • Attain standard radiographs
  • Shoe modifications, wider toe box, avoid high heels
  • Padding or tapping
  • Custom foot orthotics
  • Pain management with NSAIDS
  • Elective surgery consideration

7.Morton’s Neuroma

S: Sharp, shooting, tingling pain. Points at 3rd inter-space. Feels like a “rock” in their shoe. Hurts worse while wearing heels

O: (+) Mulder click, sullivan sign, pain upon palpation of 3rd interspace. (+) Tilex or Valleix sign. (-) edema, erythema, fracture, callus site. (-) Lachman’s test for plantar plate tear.

Radiograph: rule out fracture

A: Differential diagnosis:

  1. Morton’s neuroma
  2. stress fracture
  3. foreign body
  4. metatarsalgia
  5. plantar plate tear

P:

  • Attain radiograph or MRI
  • Perform nerve block for diagnostic test
  • Corticosteroid or 4% alcohol sclerotic injection
  • custom orthotic with metatarsal pad/cookie
  • Surgical excision

8.PTTD

S: Throbbing pain along medial arch of foot, gets worse over time. Difficulty standing for longer than a few minutes. increase swelling along medial arch of foot. No history of trauma.

O: Follow Johnson and Strom classification. (+) Pes planus foot type. Tenderness upon palpation of medial foot arch, mild swelling on PT tendon, pain following PT tendon along medial malleolus. (-/+) double heel raise, (-) single heel raise. Everted forefoot or “too many toes” sign.

A:

  1. Posterior Tibial Tendon Dysfunction
  2. Os tibiale externum
  3. Ankle Sprain
  4. Ankle Arthritis
  5. Tarsal tunnel syndrome

P:

  • Rest, Ice, Compression, Elevate
  • NSAIDs
  • CAM Boot
  • custom orthotics /FFO
  • Surgery: tenosynovectomy, FDL tendon transfer, Medial Calc slide, flat foot reconstruction

9.Intermittent Claudication/Resting Pain

S: Pain, aching, fatigue in exercising leg muscles. Gradual cramping usually unilateral. Relieved by standing still. Unable to walk more than 5-7 blocks.

History: smoking, high cholesterol

O: “Claudication” Latin for “to limp”. (+/-) DP and PT pulses. Cap refill >5 sec., No digital hair present. (+) Pratt’s test – pain upon calf squeeze. Reproducible pain by walking. Alleviated by resting. Pain returns by elevating legs, patient fells better when hanging leg over the edge of the bed. Cold feet to the touch, possible ulcerations. Stages of arterial occlusion: Intermittent claudication -> Rest Pain -> Gangrene, all caused by peripheral vascular disease (PVD).

A:

  1. Intermitten claudication or Resting Pain (PVD)
  2. Diabetic neuropathy
  3. Neurospinal disease
  4. Compartment syndrome
  5. DVT

P:

  • ABI
  • Serial pressure
  • Doppler ultrasound
  • Treadmill stress test
  • Cilostazol tables for intermittent claudication
  • Aspirin or Plavix for PVD
  • smoking cesation
  • Surgery: consult vascular

10.DMII chronic ulcer/New Diabetic pt.

S:

  • Ulcer – Red, hot, swollen foot, with a “hole” at bottom of foot. No pain associated. History of DM, PVD, neuropathy. Possible signs of fevers, chills, nausea, vomiting. Abnormal sugar levels and vital signs.
  • Or, Newly diagnosed DMII – Referred to podiatry by primary care doctor for palliative foot education. History of poor eye-sight, frequently urinates at night, and states that sometimes he “doesn’t feel where his feet are”. Currently taking first time oral Metformin. Complaints of tingling of feet.

O:

  • Neuro: Diminished vibratory sensation >10 sec. Loss of peripheral sensation with 10g mono-filament 8/10. Unable to differentiate sharp/dull test. Diminished patellar and Achilles reflexes.
  • Vascular: (-/+) DP and PT pulses, Capillary refill < 3 sec., no digital hair present, Feet cold to the touch, Doppler is mono-, bi-, tri-.
  • Derm: Wound is (5x5x2cm), base is granular/fibrotic, with serous/sangenous drainage. Does not probe to bone. No undermining, no streaking. No hyperkeratotic or macerated borders. No mal odor present. Mild peripheral wound erythema, and edema.
  • Musc: Pes cavus or pes planus, equinus present, (-/+) digital deformities.

A: A 55 year old DMII with peripheral neuropathy and associated digital deformities (high risk).

P:

  1. Educate patient on etiology of foot deformities or ulcer
  2. Educate patient on lifestyle changes and modifications
  3. Order radiographs
  4. Obtain set HgbA1c, glucose readings
  5. Debride wounds, dressing changes, order gram stain
  6. Order proper shoe-gear and socks