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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 |
Don’t Forget About the Rest of the Patient
Probably all of us have heard the statement, “There’s a patient attached to that foot.” I spent a good bit of my time during training learning to look in a more holistic manner at my patient, and pride myself on being comprehensive with my work-ups.
For example, the patient with bilateral lower extremity edema doesn’t always have chronic venous insufficiency. Their differential diagnosis must include other disorders such as hepatic, renal, and cardiac diseases. Granted, we as podiatric physicians may not be treating our patients’ congestive heart failure, but we may be the first to see its evolution. I have no problem listening for heart sounds, carotid bruits, and lung sounds. I try to remain as vigilant as possible and watch for the early signs of systemic diseases.
Much to my chagrin, then, was an encounter I had with a patient just a short time ago. I was seeing a very pleasant 72 year-old woman with unilateral painful post-traumatic ankle arthritis. She’d been ambulating with a four-point wheeled walker. She’d also had a recent fall, injuring her left 2nd metatarsophalangeal joint. After getting her MTP joint issue straightened out, I recommended a Richie brace for her ankle OA. The patient accepted my recommendation, I casted her ankle, and the braces were made and dispensed.
One month later, the patient returned to me with the same pain. She related having difficulty wearing the brace, not because of pain but due to “heaviness” of the brace. We talked further, and she began to relate a picture of chronic global weakness. She had no history of stroke and no neuropathic diagnoses. Her physical exam was benign except for core muscle and bilateral lower extremity weakness with intact upper extremities and cranial nerves.
My initial mistake was in not considering the entire patient’s issues when determining a treatment plan. If I had been more thorough and evaluated the patient’s overall strength and mobility, I would have anticipated this complication. I seemed to forget the admonition that there’s a patient attached to the ankle!
I referred the patient to a physical medicine and rehabilitation colleague, who I’m certain will take great care of my patient. After discussing all of these issues with my patient she was very happy with the plan, and I’ll hopefully see better outcomes with her in the future.
It’s always good to learn from others’ mistakes. Learn from mine, and you’ll be that much better! Best wishes.
Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum.
Best wishes.
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
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