MOC March 2015 "By a Toe"

Chief Complaint of: “MY F----IN’ TOE HURTS”

38 year old homeless man with schizophrenia notes that 5 weeks ago, while living in a homeless shelter, he began noticing pain in his left great toe.  Nothing seemed to make it better or worse, “It would just ache and burn for no reason.” He goes on to tell you that he was seen at the Happiest County Medical Center 4 weeks ago and “they did nothing for me.” A week later he was seen at your fine emergency department where records indicate that he had a normal xray and was discharged to home with a prescription for Ibuprofen. He returned to your fine facility 1 week later for the same pain.  A repeat xray was performed (negative) and he was prescribed naproxen and referred to podiatry.  He reports that the Naproxen “helped a little bit” but unfortunately he lost the medication and now the pain is much worse. He never followed up with Podiatry. 

He reports that recently he noticed some “blistering” on the toe. He is uncomfortable, very restless, and is constantly shifting from side to side in bed. He denies any trauma but admits that he “walks a lot” and could definitely use a new pair of shoes. (One whiff of his highly worn New Balance sneakers and you can’t help but agree with his personal assessment.)

Your initial differential diagnosis:

Gout

Trench foot

Occult Fracture/Stress fracture

Cellulitis

Herpetic infection (shingles)

Paronychia

Subungal hematoma

Percocetopenia

Hypo-narco-dosis

You uncase his foot from the dirtiest pair of socks and sneakers that you’ve seen since residency only to reveal a left great toe that is painful to touch and is a darkened with a deep reddish/purple discoloration.  You do not appreciate any blistering. You palpate distal to proximal: The toenail appears normal. The inter-phalangeal joint of the great toe is without tenderness and range of motion testing is normal.  The MTP joint does not appear to be red, swollen, or warm. Ankle exam is unremarkable. Calf is non-tender and there is no lower extremity edema.

You are stumped, so of course you order labs hoping they will clarify something or at least give you time to think creatively. You order a CBC, BMP, and the always helpful CRP.

You ask your colleague to look at the toe because it “just looks funny to me.” You specifically ask, “is there anything else you would do for this guy?”  Your colleague thanks you for one an exceptional olfactory experience and says “as long you document normal pulses, there is nothing else I would do.” 

Labs return unremarkable…(once again the CRP has failed to help you.)

You write a prescription for #30 Naproxen and click “discharge to home” on the computer…But something doesn’t seem right…You remember that you forgot to document his pulses so you race back to the room.  

As the nurse is midway through the discharge instructions you interrupt and awkwardly begin to check the patient’s pulses. The right dorsalis pedis pulse is normal.  As the nurse is about to discuss “reasons for return” you place your index finger in the region of the left doralis pedis pulse and feel…maybe a pulse…maybe your own pulse…whatever you feel it’s different than the left. 

You ask the nurse to “hold on a second” while you hunt down the hand held Doppler.  As you doppler the left dorsalis pedis pulse you confirm a biphasic sound.  You try to find the left dorsalis pedis pulse again only to hear a flat monophasic tone. 

          Triphasic (three clear sounds at each pulse beat): a triphasic sound indicates a very healthy artery, with no impedance to blood flow, and good elastic arterial walls. Note: The third sound may not be heard without headphones

             Biphasic (two clear sounds at each pulse beat): indicates reasonable arterial health.  

          

             Monophasic (one sound at each pulse beat): a monophasic pulse sound indicates poor arterial health, inelastic arteries and poor peripheral perfusion

             Examples:

             Triphasic Doppler: https://www.youtube.com/watch?v=mUtYCsiDWTo

             Triphasic vs Monophasic Doppler: https://www.youtube.com/watch?v=w6qhwQU9yuc

You consult Vascular Surgery and they recommend Ankle Brachial Indexes and a CT angiogram of the abdomen and pelvis with extremity runoff.

You order formal ABIs which show Normal on right and abnormal on the left : (See link for more info on ABI’s how to perform them and how to interpret them.)

http://stanfordmedicine25.stanford.edu/the25/ankle.html

You get the CT Angio with runoff and it shows:

1. Severe PAD.

            A. Subtotal distal left common iliac clot extending into the bifurcation of the

            external and internal iliac arteries.

            B. Moderately severe to possibly severe stenosis of right common iliac. 

Yikes!!!

Patient course:

The patient was admitted to hospitalist service and vascular surgery re-evaluated.

Surgical stenting was considered but the patient was very anxious about surgical intervention and preferred to wait. Adequate collateral vascular flow remained present and she was placed on antiplatelet therapy. She was instructed to return for vascular clinic to have ongoing evaluation and regular ABI’s.   

KEY LEARNING POINTS: 

- This is a tough case of multiple visits for “Toe Pain” in a patient with Schizophrenia.

- There were some triggers for a more thorough evaluation: multiple visits, worsening pain, and pain out of proportion to exam.

- Always remember: Check pulses, Check pulses, and Check pulses.

Here is something to think about as you evaluate your next patient with limb ischemia:

Also, check out a great EMRAP Podcast on Acute Limb Ischemia (Subscription To EMRAP Required):https://www.emrap.org/episode/2014/april/thelinsessions

Also, check out Michelle Lin's Paucis Verbis Summary Card for acute limb ischemia: http://www.aliem.com/paucis-verbis-card-acute-limb-ischemia/

Questions:


1. True or False: a triphasic sound indicates a very healthy artery, with no impedance to blood flow, and good elastic arterial walls. 

          

2. True or False: a Biphasic pulse sound indicates reasonable arterial health. 

3. True or False:  a monophasic pulse sound indicates poor arterial health, inelastic arteries and poor peripheral perfusion 

4. Thrombotic occlusions are usually: 

     a. Class I

     b. Class IIa

     c. Class IIb

     d. Class III

     e. a or b

5.  Embolic occlusions are usually: 

     a. Class I
     b. Class IIa
     c. Class IIb
     d. Class III
     e. c or d