Wednesday, February 18, 2015

The Foot Mystery

A/N: Not everything is as it appears at first glance, sometimes you have to dig deeper...

She was in her early forties, a tad overweight due to a penchant for that extra bite of chocolate or cookie that invariably sneaks into the office where those of the female gender congregate.  Her smile was infectious though and her easy-going manner lightened the atmosphere in the examination room as I settled onto the doctor’s stool at the computer screen.

“Good afternoon, Mrs H**,  my nurse tells me you’ve been having a boil on your foot recently,” I looked over at her and then down at her right foot.

She nodded in affirmation to my query.

“She also mentioned that you’ve recently taken some medication for it but it’s still not going away?”
Mrs H again nodded. “I just finished the antibiotic. Some of the redness has disappeared but it still pains and the swelling doesn’t seem to be getting any better.”

I glanced over the urgent care note from a few days ago. ‘Diabetic foot wound’. Ah, so Mrs H had diabetes. I wondered how well controlled her blood sugars were. Perhaps the foot wasn’t healing because her blood sugars were too high or she had some sort of circulation impairment in her feet? “Are you taking your diabetes medicine?”

“Yes,” she answered, and then added, “my sugars are always good too, 90s to 100 when I check them.”

“Excellent!” I praised. I noted in her electronic chart that her last haemoglobin A1c (a measure of how well her diabetes was under control) was 6.8 – collaborating with her reported fasting blood sugar readings. My theory about a non-healing foot wound due to poor control of diabetes disappeared. Poof! Gone. Time to figure out another reason that her foot wasn’t getting better.

“Are you having any fevers?”

“No,” she shook her head.

“How did this boil on your foot begin?”

“Well,” she began with an embarrassed shrug. “A couple weeks ago I got angry at my husband and kicked the door. I noticed pain in my foot and later it got all red and swelled up. A boil developed on my foot and then sort of burst when I pressed it. Pus came out. That’s when I went to the urgent care doctor and they gave me the antibiotic for the infection.”

“Ah,” I typed a few notes down in the computer. “So this all began a few weeks ago and the antibiotic helped but didn’t completely clear up the infection?”

Mrs H looked down at her sockless feet resting on the blue paper as if for confirmation of the fact. Noting the swelling on her right foot, she nodded in agreement with my summary.

Internally I summed up my understanding of the situation with Mrs H. Diabetes. Abscess on foot. Took antibiotics. Not better. Still painful too. Hum?

“Well, Mrs H, if it’s ok with you, I’ll take a look at your foot?”

She affirmed her consent with a nod. “It hurts here.” She leaned over from her seated position and indicated the top portion of her right foot.

“Ow!” she drew back when I pressed over the bones in her foot. I wondered if she might have fractured a bone when she kicked the door.

“Did they take x-rays of your foot last week when you went to the Urgent Care?”

“Yes, they said everything was fine. The bones were not broken,” she reassured me.

I continued to palpate around the small swollen area on the top of her foot. The good news – there wasn’t a lot of redness so the antibiotics had apparently done their job in eliminating the irksome bacteria. The bad news – there was still obviously a swollen small lump and pain on the foot.

“It feels like there’s something under the skin where you have the boil,” I looked up at Mrs H. “Any chance you might have caught a splinter when you foot hit the door?”

Mrs H thought for a moment and shook her head. “No,” she paused and then her face lit up, “my mom pulled a splinter out of my foot when I was a child.”

“Oh, what happened?”

“My brother and I were jumping on the bed. My foot got cut on the bedpost when it hit it as I fell. I told my mom there was something stuck in my foot. She said she pried out a piece of wood when she bandaged my foot.”

“Interesting,” I tried to figure out how a story of falling off the bed at the age of five related to her current problem of foot pain forty years later.

“You know, doctor, this foot has always acted up. I used to tell my mom that I thought there was still a splinter in my foot but she could never find anything when she poked around.”

“Oh?” Apparently there was more to the history with her foot than I’d originally assumed.

“Yes, doctor, my right foot has always been prone to getting a boils.”

“So this isn’t the first time you’ve had an abscess on this foot?” the light was beginning to dawn on my consciousness.

“Now that you mention it, I had something like this last year too.”

“And you’ve been seen at the doctor’s office before for this abscess and they’ve never found anything?”

“I just take the medication and it seems to go away but never completely. I get pains in the foot on and off. I have to wear shoes with socks because I can’t stand for the straps from sandals or slippers to rub on the top of my foot.”

The story was becoming more complicated. More than a one time infected skin abscess. “Do you mind if I numb up this area on your foot and see if there’s anything I can find? It feels like there’s something like a splinter or toothpick in your foot.”

Mrs H agreed to my exploratory mini operation. After numbing the area with local anaesthetic, I nicked the skin over the strange solid thing that I’d felt on my exam. If nothing showed up on x-ray, it must be something organic stuck in the foot. With a fine forceps I dug into the tissue and snagged the object I’d felt.

“It looks like you’ve been keeping half a toothpick in your foot,” I pronounced to Mrs H with a triumphant smile. I held out the forceps that now grasped almost an inch long wooden splinter extracted from her foot.

Mrs H adjusted her glasses and leaned forward for a closer examination.

“It looks like you were correct. You did still have a piece of that bedpost in your foot. You want to take it to show your mom that you were right?”

Mrs H laughed. “After all these years…”

“You’re foot should heal up properly now. Without that piece of wood irritating the tissue, you shouldn’t have any more problems.”

“Wow, doctor. That’s great.” She continued to smile, still somewhat in shock, I think. She had me put the wood in a plastic wrapper for her; and in fact, did take it home. I can only imagine what she told her family.

1.     Things are not always as simple as they might appear at the onset of a clinical situation
2.     Don’t try to keep a splinter in your body for years – it festers!

“Why do you see the speck that is in your brother’s eye, but do not notice the log that is in your own eye? Or how can you say to your brother, ‘Let me take the speck out of your eye,’ when there is the log in your own eye? You hypocrite, first take the log out of your own eye, and then you will see clearly to take the speck out of your brother’s eye.” Matthew 7:3-5

“As you slide down the banister of life, may the splinters never point the wrong way.” –Irish Proverb

**All identifying data including specific circumstances altered to protect identity.