Jarrod Shapiro, DPM Practice Perfect Editor Assistant Professor Dept. of Podiatric Medicine Surgery & Biomechanics College of Podiatric Medicine Western University of Health Sciences St. Pomona, CA

There's a Patient
Attached to That Foot

Most of us have heard the phrase, "there's a patient attached to the foot", sometime in our podiatric training. Clearly this is the instructor's attempt to emphasize that the rest of the patient's health is pertinent to the particular issue in the foot. I've tried to make this concept a guiding principle in my own approach to patients, and the further along I get in this profession, the more I think about the overall patient.

However, despite this common admonition, I'm constantly surprised by the failure not only of some lower extremity specialists but other physicians to appreciate patients' health when caring for the foot.

Here's an example with some changes to protect anonymity. A patient of mine underwent surgery for infection at one of my local hospitals. During this patient's stay in the hospital, a diagnosis of DVT was made and the patient was appropriately started on Coumadin^® prior to discharge. The patient left the hospital with a negative pressure device and began follow up in my clinic. About ten days later, home nurses noticed bleeding through the negative pressure device. They redressed the foot thinking it had something to do with the device, but a few days later the patient became concerned due to continued bleeding. He went to a local emergency room where the device was supposedly repaired and the patient sent on his way.

A week later I saw the patient in my office. The wound had chronic hemorrhage though no current active bleeding. It was clearly apparent that the only reasonable explanation was that the patient had a Coumadin^® coagulopathy. His Coumadin^® dose was too high, leading to bleeding from his wound, worsened by the negative pressure device.

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The most unfortunate part of this episode was that during this time, the patient saw not just one doctor in the ER but a second doctor (his primary care physician), and neither of those physicians thought to draw an INR or PT. Clearly this patient suffered from the tunnel vision of someone who stopped thinking about the entire patient and focused simply on the foot. It wasn't until the patient reached a podiatric clinic that his entire medical history was considered.

From my experiences with these types of patients, I would make two primary recommendations:

First, at the patient level, any time your patient does not improve after standard therapy or the complaint is odd in some way, consider a cause proximal to the foot.

How often do you see patients with heel pain that someone has previously diagnosed as plantar fasciitis, only to find out later that the patient actually suffered from a lumbosacral radiculopathy? For me, this is a relatively common occurrence with those patients seeking a second opinion for recalcitrant heel pain. A similar issue may occur with limb length discrepancies. This all too common issue is often involved with previously unsuccessful heel pain treatment.

Similarly, I once had a young patient that presented with a nonpurpuric, nonblanching petechial rash on both arches of her feet. Her father had a history of stroke at 35 years of age. Things just didn't look right to me, so after obtaining a full history, I ordered some labs, and it turned out she had a hereditary clotting disorder. I could have just diagnosed her with tinea pedis or dermatitis and sent her on her way, but I would have been wrong. Thinking outside the box in the case of this patient's foot may potentially have saved her life.

Second, on a larger scale, I suggest to the organizers of our large conferences that they add in more comprehensive tracts covering general medical issues, updating us on the latest advances and issues in medical care.

We spend so much time at our conferences listening to lectures about such-and-such surgical procedure or the next great fixation device, but we need to continue to educate ourselves on the rest of our patient. Did you know there is a new JNC 8 document with new guidelines for hypertension management? Do you know what JNC is?  Do you know about recent cardiac advances that might affect your patients with lower extremity edema? How about chronic renal disease's affect on the lower limb?

I'm not suggesting we become experts in treating hypertension, kidney disease, or any other general medical disorder. However, we keep telling the national community that we are physicians who treat the foot and ankle. If that's the case, then we need to continue to think above the foot, maintain our education, and use it to benefit our patients.

I can only cringe when I think about my own past patients who might have received better diagnoses and treatments from me if I hadn't stayed in my silo of the foot. I hope to continue to improve into the future. How about you?

Best wishes,

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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