Rearfoot / Ankle · Infection & Wound · Medicine & Peri-op · Advanced
Horseback Thorn
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 ankle is red, hot and killing me."
62-year-old man with non-insulin-dependent diabetes, called to the ER at 8 PM for a possible surgical case.
History of present illness
Red, hot, swollen RIGHT ankle with significant and worsening pain for 4 weeks.
- Punctured by a large thorn over the right ankle while horseback riding about 5 weeks ago
- Redness has progressively spread and pain has become severe
- Last meal about 8 hours ago (NPO status relevant if he needs the OR tonight)
- Fever and malaise: reports subjective fevers
- Has not had an incision, drainage or imaging before this visit
- Tetanus status: unsure, last booster more than 10 years ago
Questions a strong candidate asks at this step
- Onset, duration, progression of redness, swelling and pain
- Mechanism: what penetrated, where, depth, organic (plant/soil) material, footwear, was anything retained?
- Treatment so far: wound care, oral antibiotics, steroid or colchicine for 'gout', NSAIDs
- Last meal / NPO status; tetanus immunization status
- Fever, chills, rigors, nausea, malaise; glucose control at home
- 6 Ps: pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia
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.