Forefoot / Midfoot · Diabetic Limb & Charcot · Vascular · Advanced
Missed Follow-up
Podiatric surgery residency interview case. Work through it the way you would at an interview: take the history, ask for the exam and imaging, then commit to a diagnosis and plan.
Chief complaint
"My big toe hurts and the sore won't heal."
43-year-old woman seen in the emergency department with a painful, ulcerated right hallux.
History of present illness
Chronic dorsolateral superficial ulcer and a plantar ulcer of the right hallux, present about 3-4 months.
- Around the time the wounds began she was admitted to a hospital in another state for the right hallux, received IV antibiotics and had "a portion of the bone removed"
- At discharge she was given no oral antibiotics and no outpatient follow-up
- Records show she was seen by podiatry as an inpatient consult 4 months before this visit: the hallux was stable with dopplerable pulses; local wound care and antibiotics were recommended with outpatient noninvasive vascular studies and podiatry clinic follow-up, which never happened
- Pain in the whole right leg
- No reported fever, chills or rigors; no drainage or odor noticed by the patient
Questions a strong candidate asks at this step
- Onset, duration and course of each ulcer; what started it (trauma, shoe, nail, blister)
- Prior treatment: hospitalizations, IV/PO antibiotics, prior bone resection or other surgery on this toe
- Follow-up since discharge: wound care, who changes the dressing, access to clinic and transport
- Pain: rest pain, night pain, claudication, distance walked
- Drainage, odor, redness, swelling; fever, chills, nausea, vomiting, malaise
- Numbness, burning, loss of sensation
Present the rest of the case
Past history, exam, imaging, assessment, plan and discussion questions, with model answers, are in the interactive trainer. The diagnosis is kept there on purpose so you can practice committing to one.