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.

Moral:

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.

Medical Mysteries: Stomach Bumps and More...

Medical Mystery – Can you guess the diagnosis?

Homo sapiens are arguably the oddest of the mammalian lineage. Practically hairless, given to odd bursts of extreme emotion, prone to ingesting substances that impair their chances of survival and transference of genetic code, and, speaking of code, possessing a penchant toward cryptic messages of intentional and unintentional consequences. From the forensic investigator to the elementary school teacher and even the family doctor, these peculiar tendencies of the human race generally serve to reduce the ennui at least.

I am not a forensic pathologist, nor am I a teacher (thank goodness!) – I do see a fair number of sick people on a regular basis – some more ill than others in spite of their opinions. As physician, it is not always obvious what the precise problem is that ails a client seeking medical attention. Part of the job of a physician is to question, to examine, to explore and test the possibilities and come up with the diagnosis. On occasion, if doctor and patient are fortunate, finding the problem or diagnosis will help lead to the solution or cure. The difficulty typically lies in determining the precise detail of the patient’s problem, physical, mental, emotional… or all of the above? This process is not always as straightforward as one might imagine, or read about in the standard medical textbook. 

Humour me as I set forth a few recent examples to illustrate my point.

Case 1:  The Case of the Mysterious Stomach Bump (part 1)

AC was a 17-year-old teenager. A typical schoolgirl. On the examination table she fidgeted nervously and smiled awkwardly as I reviewed her medical history and lab results with her.

“So, you’re here because you are having irregular menses,” I read the chief complaint listed on her encounter form.

“Yes, doctor.” She waited for me to continue.

I skimmed the rest of medical history and summarised. “It looks like you missed your period in last month and now this month but otherwise, you have no other problems.” I glanced in her direction.

She nodded in affirmation.

“Have you ever missed your period before?”

“No.”

“So prior to last month, your period came every month?” I re-stated the question for clarification.

“Yes, doctor,” she replied and then hurried to explain. “When I didn’t have my period, I did a pregnancy test. I’ve done five tests.”

“And?” I waited for an answer.

“They were all negative but I still haven’t seen my menses. It feels like it wants to come but it hasn’t come.”

I looked at the lab result in her book. The nurse who had initially assessed her had already sent her to the lab and had them check a urine pregnancy test.

“It says here in your book that your test today was negative.”

She nodded.

I rose and came over to continue with the physical examination portion of our visit. Eyes, ears, nose, throat… all unremarkable. Heart sounds normal. Lungs were clearly working well with no signs of asthma or pneumonia. There were no stigmata of HIV infection. Nothing stuck out on the exam until I reached her stomach. My examining fingers explored a large, firm mass in her stomach.

“How long have you had this [mass] in your stomach?” As I palpated the smooth contours of the firm bulge in her abdomen she did not appear to have any discomfort.

“For long, doctor. It’s been for long.”

“How long is long? A week, a month, years…?” I probed for a more precise time period.

“Since I was little,” she answered.

“Your belly has been like this since you were a little child?!” Her answer was rather unexpected.

“Yes, doctor,” she affirmed sincerely.

“You have had this lump,” I pushed on the large abdominal bulge in the middle of stomach for emphasis and clarity, “since you’ve been a child?”

“Yes, doctor.”

“And how long have you noticed your stomach getting big like it is now?” I was not convinced.

“As long as I can remember, doctor.”

Now, you have your case. History. Physical exam. Lab tests: Seventeen-year-old female. One month, almost two months, with no menstrual period. Large stomach mass from infancy. Negative urine pregnancy test.

Diagnosis?

Case 2: The Case of the Mysterious Stomach Bump (Part 2)

She came with her father. Chief complaint: ‘fever and weakness and chest pain’.

“She’s not well,” her Father stated the obvious as his daughter resignedly climbed onto the examination bed. I grabbed her arm to steady her as she wobbled precariously a few times in her attempts.

“How long have you been sick?” I asked.

“Four years,” her father promptly replied.

“Four years?!” I raised my eyebrows in surprise. “You’ve had fever for four years?” I tried to clarify things a bit.

“No, doctor. The problem is her stomach. It pains her,” her father corrected while his daughter remained quietly exhausted on the exam table.

“Ah,” I nodded. “So there are two problems – fever that’s been of recent and then the stomach pains for four years.”

Her father gave me an affirmative nod. “The stomach, it’s pained her for long. She is not well. She drink plenty medicine but to no avail.” His palms turned upward in a gesture of helplessness. “The stomach has too much pain, she’s not well….”

He continued to elaborate on the severity of his daughter’s stomach while I perused her medical booklet. Hum… a blood transfusion?  Haemoglobin 6.7 g/dl. That’s interesting.  Ciprofloxacin. Anti-malarial medicine. Analgesics. Anti-spasmotics. The father was right – there was a long string of antibiotics and other medications that she had taken.

“What kind of problem with her stomach does your daughter have? What have you been told?”

“I don’t know, doctor,” he shrugged.

“Has she ever had a blood transfusion?”

“No.”

I asked a few more questions as the picture of her past hospitalizations came to light through my inspection of the various treatments and lab tests done. Somewhere there was a line that read, ‘enlarged spleen.’

“Has anyone told you that HF has a large spleen or mentioned the need for surgery?”

“No, doctor,” HF’s father shook his head while his daughter did not add anything to the contrary.

I stood up to do the physical exam.

“How old are you?” I addressed HF directly this time.

“Sixteen,” she whispered.

I was puzzled. The last entry in her book was over a year ago. Why wait until she had a high fever to come to the doctor for an obviously chronic problem.

I looked down at her abdomen. It was clearly bulging. On palpation, I felt a firm mass on the left side where one normally feels only soft intestines. There was more mass filling up her stomach below her naval too.

“Are your periods regular?” I inquired.

She nodded, yes.

“Can you go to school?”

“No. She cannot even go to school because of her stomach,” her father interjected emphatically.

Interesting. 16 year old female with a mass in her stomach and too weak to continue her studies in school.

One diagnosis or multiple?

Case 3: The Case of the Mysterious Stomach Bump (Part 3)

Madam was a tired 34-year-old client. I called her name in the waiting area and found her sleeping, stretched out on the patient bench getting a rest.

“You are having fevers, weakness, headache, lack of appetite, back pain, and ‘something moving in my stomach’?” I looked up from her medical book.

She nodded wearily.

“Anything else?”

“Dizziness.”

I glanced over her blood pressure, temperature, and pulse that were essentially normal. “When was your last menses? It says here that it was in August (1 month ago). Are you pregnant?”

She shrugged. “I don’t know, doctor.”

“Have you been pregnant before?”

“Yes, doctor. My youngest is 1 year and 4 months.”

“And you feel something moving in your stomach?”

She nodded.

“Like a baby moving inside?” I noted her protuberant stomach and felt the rounded mass of her uterus.

“I don’t think your last period was in November.” Apparently this past week has attracted a large number of ‘spontaneous’ pregnancies. I was getting used to the vague answers and lumpy bellies now. No need for a pregnancy test this time! Besides, Madam has just put to birth relatively recently. She wasn’t naïve to the signs and symptoms of pregnancy.

Denial is a powerful tool…

“I can’t be pregnant. My baby is only one year and four months,” she repeated.

“Were you using anything to prevent pregnancy, family planning, contraceptives…?”

She shook her head.

I put the ultrasound probe on her lower abdomen that bulged out at the naval.

Diagnosis?

Case 4: The Case of the Worried Man (for something different)

On average, the male species tends to avoid hospitals, clinics, and doctors in general (unless they’re Hollywood actors that play the role of doctor). When a man comes in without his woman, you can be fairly certain that the problem is important to him.

JJ was 28 years old. He worked in the construction business and helped to build all the local cement multi-storey structures that are popping up locally in Buea and the surrounding area. He was short and stocky and strong.

He entered the consultation room hesitantly. “Please, sit down.” I indicated the chair opposite mine.

He glanced around, scoped out his surroundings, and finally seated himself.

“What brings you to the hospital today?”

He was quiet for a few moments. I waited. His medical booklet noted that he had “left testes pain”.

JJ gathered his thoughts together and began, “I have pain here.” He pointed to his groin. “It’s not all the time,” he assured me.

“Ok…” I waited from him to continue.

Awkward silence.

“That’s all.”

That was all from his perspective. I still had questions. Starting with his concern over the pain, I asked all the other usual medical questions that can help narrow the problem. He answered them all very succinctly.

His exam was, not surprisingly, unremarkable. “No hernia,” I reassured him. “Everything on exam is normal so far.”

He nodded.

Given the topic of the day, I seized the opportunity to do his STI (sexually transmitted infection) labs: syphilis, gonorrhoea, Chlamydia, HIV. He agreed.

“Oh, doctor,” he paused as he gathered his briefcase, “I forgot to mention that my leg,” he touched his left leg, “sometimes it feels numb, like it wants to die inside.”

I nodded as I added this random factoid to his review of systems. JJ then went off to the lab for his tests.

An hour later, the tests were complete. I looked at the results. I had a diagnosis.  Do you?

Case 5: The Case of the Mysterious Stomach Bump (Part 4)

I briefly reviewed the initial history of KC before inviting her back to the consultation room. “Abdominal swelling” – could be interesting or not. Nothing else jumped out at me from the notes.

“So, you’re here because you are worried about the swelling in your stomach?” I queried when KC had seated herself across from me?

“Yes, doctor,” she twisted her scarf between her fingers and lowered her gaze.

“Can you tell me more this problem?”

“My stomach, it’s swelled.”

“Anything else?”

She shook her head.

“Can you tell me how long your stomach has been swollen?”

“For long, doctor.”

“And have you been to the hospital for this problem in the past?”

She nodded but did not elaborate.

I resorted to reading the details in her medical book. There were the usual suspects: typhoid, malaria, and stool analyses along with their respective treatments. I didn’t see anything that would explain her swelling.

I stood up and addressed KC again who’d been sitting patiently while I sifted through loose papers and tattered pages. “Come up to the exam bed and we’ll examine your stomach, ok?”

She acquiesced. “Any pain?” I prodded her stomach.

“No,” she answered easily.

No big spleen. No big liver. No masses, actually. Lying supine on the bed, her stomach didn’t appear impressively swollen. I decided to do a small ultrasound. I’m not an expert in the nuances of deciphering abdominal pictures but sometimes problems can be rather obvious. This happened to be one of those cases. Diagnosis?

 Case 6: The Case of the Mysterious Stomach Bump (Part 5)

LL was an energetic young 25 year old woman. She practically bounced into my consultation room, leaping up with enthusiasm when I called her name in the waiting area. (Of course, part of this could have been the rather extended time she was waiting…)

“Welcome. Come, sit over here.” I invited LL to situate herself on the blue examination table in front of me.

“How was your Christmas?” I looked up from glancing over her medical book.

“Fine, doctor.” She smiled.

“You already did a pregnancy test, I see.” I noted the red ink indicating a negative urine pregnancy test this morning.

“Yes, doctor.”

“How come?” Her last period was just under a month ago.

She shrugged. (Not the most helpful answer)

“Ok. Any other complaint?”

“My stomach’s too big, doctor.”

“Does it pain you? Are you having any problems with your stool?” I wondered if there was a hidden concern within her statement.

She shook her head. “No, it doesn’t pain.”

“Was your last menses normal?”

“Yes.”

“Are you menses regular – you see them every month?”

“Yes.”

Still unsure of her real reason for consulting, I continued with the examination. “Why do you think you might be pregnant?”

“I don’t know, doctor.” She gave a half-embarrassed shrug and smile.

“Is there a chance you could be pregnant?”

“I don’t know.”

“Do you feel pregnant?”

She shrugged.

“Do you want to be pregnant?”

“I don’t know, doctor.”

Again, not the most revealing of answers!

I finished my physical exam. There was nothing remarkable. Her stomach soft, squishy, and lump-free. There was nothing to indicate anything to contradict her negative pregnancy test.

“Well, I don’t think you’re pregnant,” I finally concluded. “Your test today was negative for pregnancy and when I examine you there is nothing to say you might be pregnant.”

LL sat up. “But, doctor, why is my belly getting bigger?”

“What do you mean?”

“I’m not eating too much but my stomach is still coming out.”

She did have a point. Her abdomen did have a small, rounded bulge to it’s contours.

I shook my head. “Well, it’s not getting big because you’re pregnant,” I reassured her.

“Then why, doctor?” She insisted.

“Um… maybe you’re eating more and it’s fat?” There was nothing to indicate anything was abnormal. I re-examined her stomach and placed the ultrasound probe on her belly to pacify her persistence.

At the end of my second exam, I made my final diagnosis. What do you think?

Answers:


Case 1: Remember how humans are a strange species given to cryptic messages? ... the ultrasound on 17 yo girl with abdominal mass since childhood and no menses for over a month showed a single baby. She was 5 1/2 months pregnant. Yes, I do believe she'd missed more than one period!




Case 2:Young girl with fever and large abdominal mass and weakness... massive splenomegaly with malaria and an Hb of 9.6 (not pregnant!)




Case 3: Pregnant, 5 months + malaria. As my clever friend, Laura, pointed out -- "a parasite and parasites".




Case 4: The worried man with the testicular pain (sometimes) and occasional numbness in the leg -- well, can't really explain the pain in his groin but it's good he did his STI work up - HIV positive. Sometimes the doctor finds more than they want wrong.




Case 5: Ultrasound revealed ascites -- fluid in the abdominal cavity. Not sure why she had ascites since she was otherwise generally healthy.




Case 6: Excess Adipose Tissue - fat. This energetic 25 yo female was quite healthy, actually. She was not pregnant. She did not have a big spleen or a big liver. She did not have ascites or a uterine fibroid. In fact, she didn't have anything IN her belly. She had just gained a bit of weight - belly fat - nothing more :-)