AAFP Orange County Chapter Case of the Month

1. AAFP Orange County Chapter Case of the Month Lance Brunner M.D. Assistant Program Director SCPMG Orange County Family Medicine Residency Program

2. Case Presentation • 67 year old male presents with a 1 month history of a swollen left foot. Does not recall any specific trauma. Scant pain if any. Swelling worsens after walking. No open sores on the foot. The patient does state that the foot feels warm

3. Case Presentation • PMHX • Type 1 DM with • mixed hyperlipidemia • CKD 3 • Peripheral neuropathy • CAD • stable angina pectoris • RTA 4 • PVD • Gout • Osteoarthritis

4. Case Presentation • PSHX • Total hip replacement on the right • Allergies • Amoxicillin • Meds: • Lantus • Lopressor • ASA • Lisinopril • Amlodipine • Simvastatin • Allopurinol

5. Case Presentation • FHX: • CAD • DM • Colon Cancer • SHX • No tobacco products • One drink a week • No drug use • retired postal worker • Married with 2 children

6. Case Presentation • ROS: • No fever • Some limping with ambulation • No claudication symptoms • No knee or hip pain • No calf swelling

7. Case Presentation • Physical Exam • General: Afebrile, BP 110/70 rr 12 pulse 82 • CV: RRR without murmurs/rubs/gallops/ heaves • Lungs: CTA • Abdomen: soft, NT, ND, NABS

8. Case Presentation • Ext – left foot: • Impaired proprioception, 2 point discrimination, and pain discrimination, DP not palpable, foot warm, + dependent rubor, + lack of hair on shin and toes, + forefoot swelling without tenderness to palpation, also slightly swollen medial malleolar and moderately swollen lateral malleolar region

9. Case Presentation • Left foot standing x-rays – read as negative • Diagnosed as likely forefoot sprain • ACE, ICE , Elevation, tylenol

10. Case Presentation • Patient returns 2 weeks later, no better, actually worsening, still limping • Exam the same except now increased left foot swelling including medial and lateral malleolar swelling

11. Ankle arthrocentesis by Family Medicine MD: Crystals negative Culture negative Bloodwork WBC 7.0 Uric acid 9.4 Concern about gout exacerbation with pain masked by neuropathy Patient placed on a prednisone pulse and asked to follow-up in a week Case Presentation

12. Case Presentation • Patients returns a week later – no improvement • Repeat weight-bearing foot x-ray – questionable cortical irregularity of 2nd and 3rd metatarsal region of the left foot

13. Case Presentation • Urgent bone scan of the foot – consistent with charcot ankle/foot and 2nd/3rd metatarsal fracture, later confirmed by MRI • Patient seen by orthopedics and placed in a cast – now in an ankle foot orthosis

14. Case Presentation • Learnings (among others): • Patients with peripheral neuropathy may have symptoms consistent with an occult fracture (pain) that are masked • Findings of an early fracture may not appear on the first radiograph – consider repeating the radiograph in a week and/or getting a second opinion on the first reading. If still uncertain, and concern remains that a fracture is present, consider another form of imaging such as a bone scan (sensitive but not specific) or MRI (as sensitive as bone scan but higher specificity) • Consider underlying charcot arthropathy in patients with peripheral neuropathy