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GRAND ROUNDS
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Conditioning Exercise for the
Residency Rumble
I’ve seen many of the nation’s residents at journal clubs, grand rounds, and
regional seminars. Frankly, none of you look like you’re in shape for the
Residency Rumble.
You’re all puny, worthless and weak!!
Who among you is worthy of the title
PRESENT Residency Rumble Champion ?
The following case presentation is designed to get you into shape.
Case
Presentation
This is a 63-year-old male who presented
to the office with enlarging prominences along the medial and lateral margin of
the 3rd toe, left foot. Initial onset was approximately three years ago. The
patient’s symptomatology is very limited.
PAST MEDICAL HISTORY: This is essentially
unremarkable.
MEDICATIONS: None
ALLERGIES: NKA
SOCIAL HX: Not a smoker. Drinks 2,3 glasses red
wine daily (Hint).
NEUROVASCULAR EXAMINATION: The patient’s
neurovascular status is intact. Pedal pulses are graded +2/+4 bilateral.
Propreoceptive sensoriums are intact. The skin is supple and well hydrated. The
nails are normal.
LOWER EXTREMITY EXAMINATION: Clinically one notes
large prominences along the medial and lateral wall of the 3rd toe. The lesion
appears to be well circumscribed. There is no bleeding or discoloration to the
toe. There is some narrowing of the proximal interphalangeal joint space
(Hint).
Pre Operative radiograph
(2
small hints exist here)
PLAN: In light of the patient’s limited
symptomatology, an aggressive approach to this problem may not have been
warranted. We discussed biopsy of the lesion with possible excision. I explained
to the patient that there may be some difficulty associated with complete
excision. If it is determined intraoperatively that complete excision would be
difficult, we will await results of the biopsy and return to the OR only if
necessary.
Pre Operative appearance
To maximize exposure, a reverse “Z” incision was made. The medial arm extended
proximally.
A well
circumscribed lesion was encountered which extended down to the joint surface.
The articular surface was covered with a substance similar to moist talcum
powder
(Hint)
A revision of the skin edges was performed.
Skin closure
The specimen sent in alcohol
(Hint)
Hint: View
John Hembree's lecture on Gout for more insight
Some Gout Facts
Gouty tophus are deposits of sodium urate in the tissues. Tophi contain soft
creamy deposits which become hard with time. Gouty tophus are relatively
painless while an acute gout is known to be agonizing.
Curiously, this gentleman had no hx of gout or hyperuricemia.
When measured in the office, the Gout
patient's Uric Acid is usually normal, as they are usually already finishing
their acute attack. It is considered good medical practice, however, to
measure serum Uric Acid, to establish the patient's baseline.
Share your unique and interesting cases with us!
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Jay Lieberman, DPM
Editor - PRESENT
Director of
Podiatric Medical Education
Northwest Medical Center
Margate,
Florida
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