Category Archive: Resident News to Use

ABPM Spotlight! Meet Director, Mitchell Shikoff, DPM

Mitchell Shikoff, DPM

Dr. Mitchell Shikoff has been a Diplomate of the ABPM since 1989 and has served on the board since 2009. Dr. Shikoff has several roles as a Diplomate of ABPM; he is currently the Vice President, Chair of the Case Document Review Committee, Chair of the Credentials Committee, serves on the Speakers Bureau, and formed the Marketing Committee on which he is extensively involved. Dr. Shikoff is also the ABPM representative to the American Podiatric Medical Association (APMA), the American Board of Foot and Ankle Surgery (ABFAS) and the Joint Committee on the Recognition of Specialty Boards (JCRSB), where he has served as the Chair. He represents both the ABPM and the ABFAS as a residency program reviewer for the Council on Podiatric Medical Education (CPME).

“My time serving as a Director of the ABPM for the past ten years has been challenging and rewarding. I’ve been able to be part of a transformational process of the ABPM and witness astounding growth in membership and Diplomate value. I am proud of the significant changes and encourage all residents to attain certification promptly. Finally, get involved with the Board on one of the many committees and run for a position as a Director. It will keep you at the forefront of your chosen profession.”

Originally from Northeast Philadelphia, Pennsylvania, he completed his Bachelor of Science and Bachelor of Arts undergraduate degrees at the Pennsylvania State University in 1979. Dr. Shikoff received his Doctor of Podiatric Medicine in 1983 from the Dr. William M. Scholl College of Podiatric Medicine in the Rosalind Franklin University of Medicine and Science. He completed his post graduate surgical training in St. Louis, Missouri. Dr. Shikoff has offices in Bensalem, PA and Feasterville, PA since 1985 and continues to take advanced training in various aspects of Podiatric Medicine, Surgery, and Wound Care which most recently includes new biologic wound dressings and Hyperbaric Oxygen Therapy. Dr. Shikoff has served as a residency director of a three year PMSR program, and thoroughly enjoys training residents at the hospitals where he is an attending.

As a dedicated husband and father of two, Dr. Shikoff has many interests outside of Podiatry. He enjoys bicycling, skiing, scuba diving, fishing, traveling, and spending quality time with the family.

Outpatient vs. Inpatient Workup of Diabetic Foot Infections

By: Marisse Lardizabal, DPM,

Diabetic foot infections (DFI) are both challenging and common amongst all podiatrists. Treatment of DFI’s require a level of comfort and training as well as resources available to clinicians. ABPM has traditionally been a great source of information for podiatrists which makes the board certification by ABPM paramount.  Like many podiatrists, you may encounter these types of patients initially in the clinic/outpatient setting, where you can catch the potential signs and symptoms of a diabetic foot infection waiting to happen.

First, nothing can substitute a thorough History and Physical Exam on a patient.  A complete NLDOCAT will give one a lot of information as well as develop a story as to why the patient is presenting with a diabetic foot infection.  For example, time frame of the ulceration, how well the patient’s diabetes is controlled, and any prior and/or current ulcerations will help you formulate a treatment plan. This may also foreshadow how compliant a patient will be with their recovery.  A thorough physical exam is of significant value when looking for classic clinical signs of infection, as well as the status of the neurovascular structures. Does the patient have enough circulation to heal an ulcer? Is a referral to a vascular surgeon necessary? Obtaining radiographs and necessary labs (CBC, CMP, ESR, CRP) should be obtained for a complete work up.

The Infectious Disease Society of America Diagnosis and Treatment of DFI, also known as IDSA Classification, is one of the most helpful guidelines that should be utilized by clinicians who treat DFI routinely. This guideline classifies DFI based on severity of the infection, clinical signs, and constitutional symptoms presented. IDSA also makes recommendations of what the appropriate treatment course should be.  For example, consider a patient who presents with erythema <2 cm around the ulcer with 2+ signs of infection. According to the IDSA guidelines, the patient’s infection is classified as “uncomplicated soft tissue infection” or Mild DFI. Therefore one may feel comfortable sending the patient home with oral antibiotics, local wound care and offloading as well as a 3-5 day follow up to see if the signs of infection have resolved.

Moderate DFIs (erythema > 2cm with 2+ signs of infection present) are the most challenging to classify and treat. Without close observation, these patients can potentially get worse and can be very much considered as admitting criteria depending on presentation of the infection.  At times, these patients can benefit from a decompression of the infected foot in the clinic setting, while making sure wound cultures are obtained prior to discharge. If patients are discharged home, close follow up and monitoring is essential. If symptoms do not improve, the safest course of treatment may be hospital admission for IV antibiotics and possible surgical interventions.

 

Lastly, severe DFIs are complicated local infections in conjunction with the patient endorsing constitutional symptoms as well as presence of SIRS criteria. These are the patients that will be admitted to the hospital for surgical management of the infection due failure of conservative treatment.  The IDSA guidelines are key elements to be familiar with as they will guide your treatment and tell you which patient will need a higher level of care.

Once the patient is admitted to the hospital, inpatient work up of DFI is very much similar to the outpatient setting.  If admitting the patient under Internal Medicine, it is important to communicate necessary labs, imaging, choice of IV antibiotics, NPO status as well as plan for surgical intervention to the service for an efficient and effective hospital course.  One may consider advanced imaging, such as an MRI (preferably prior to surgical intervention), whether there is concern for osteomyelitis or abscess in the foot.  The advanced imaging should by no means delay surgical intervention if it is considered emergent.

This brief overview of triaging DFIs can hopefully streamline how DFIs are treated in one’s practice.  Effective treatment of DFIs is our expertise and it will benefit our patients to have a standard of how it is treated.  Being board certified by ABPM, I feel confident in treating DFIs with the knowledge and background that I continually use in my daily career as a Podiatrist.

 

References:

Clinical Infectious Diseases, Volume 54, Issue 12, 15 June 2012, Pages e132–e173, https://doi.org/10.1093/cid/cis346

ABPM Spotlight! Meet ABPM Director, Coleen Napolitano, DPM

Coleen Napolitano, DPM

Coleen Napolitano, DPM

The ABPM welcomes Dr. Coleen Napolitano as the newest member of the ABPM Board of Directors. Dr. Napolitano has been a Diplomate since 1994 and has been active with the ABPM for the past 15 years, primarily with the Examination Committee, where she is the current Chair of the certification exam (Part 2) sub-section.

“I am quite familiar with the ABPM’s past and present and have witnessed first-hand the significant strides it has made in the medical community, said Dr. Napolitano.  “I look forward to contributing to the future of ABPM and believe that ABPM certifies specialty skills that represent the majority and the best of podiatric care, witha focus on medicine and podiatric orthopedics.”

Dr. Napolitano did her undergraduate at Florida International University on a running scholarship.  She obtained her doctorate and Bachelor of Science from Dr. William Scholl College of Podiatric Medicine and completed her residency training at Hines Veterans Administration Hospital in Illinois.  Dr. Napolitano followed her certification with the ABPM by becoming ABFAS certified and encourages podiatry residents to recognize the benefits of dual certification.

She is currently an Associate Professor in the Department of Orthopaedic Surgery & Rehabilitation in the Section of Podiatry at Loyola University Medical Center and is the Program Director for the podiatry residency training.

Clinical Presentation Skills: Communication with your Patients

Faith A. Schick, DPM

Faith A. Schick, DPM

By: Faith A. Schick, DPM

The ability to communicate with your patients is integral to successful outcomes.   This is an important practice skill that should be developed and mastered prior to graduating residency.

As a resident, I recall spending time shadowing multiple physicians.  After a period of time, I was able to know what the physician was going to say before the words came out of his/her mouth.  This wasn’t because I was getting smarter at understanding how I was supposed to treat a specific condition,  but because I became familiar with the conversation the attending was going to have with the patient.  As time went by, and after many experiences, I was able to synthesize different versions of what I was hearing, and have specific treatment plans I would share with my patients when the time came.

Developing this organized thought process helped to ease the transition from resident to attending.  When the time came I was ready.  I knew how I wanted to treat my patients and what supplies I needed to perform an appropriate physical examination and render care.  Being board certified with ABPM and though my experiences I knew I could handle any situation. I was able to walk into the treatment room with confidence and explain to my patients what I thought their condition was, and how we were going to manage it without faltering.  I knew what I wanted to say before I said it, similar to the physicians I had observed.    This confidence reassured my patients.

Realize that just because what you are saying makes sense to you, it doesn’t necessarily mean that it is going to make sense to your patients.  During residency you are surrounded by peers who easily communicate using medical terminology.  Once in practice this changes, and your audience becomes your patient population.  Language needs to become more simple; you need to still speak intelligently, but use words that your patient will understand.  For example, instead of saying “calcaneus”, explain by saying “heel bone”.  While it may make sense to you that a patient should sleep in their CAM boot, you need to very clear with patients giving them instructions.  Make sure to ask if your patient has any questions before leaving the room.

Think about the message you are trying to convey.  How do you sound?  What does your posture look like?  Are you making good eye contact?  As time has gone by, I have come to appreciate the value this has on my office workflow.  I am able to review my chart notes with ease knowing that there is an organized thought process as to how I treated my patient during their last visit, and depending upon their outcome how I plan to proceed with care.  My staff is able to anticipate my needs and the needs of my patients.  Appointments are scheduled in an organized fashion based upon the diagnosis.  With the advent of electronic health records, I have been able to develop templates that facilitate my documentation process.  Patients are able to leave the office with organized instructions explaining their diagnosis and plan of care.

This level of organization assures that I do not miss any step in my patient’s treatment.  By the time the patient has completed their visit to the office they have an established diagnosis with plan of care, all questions have been answered, necessary studies having been ordered, medical supplies have been dispensed, and a follow up appointment has been made as needed.  This limits my liability and the chance that something gets overlooked or forgotten.  All too often physicians are multi-tasking throughout the day and a simple distraction can lead to error.  Having an organized treatment algorithm keeps things on track to make sure nothing gets missed, and communication with your patients is of utmost importance.

 

Clinical Presentation Skills: Owning and Operating a Successful Private Practice in Today’s Healthcare Climate

By: Daniel T. Hall IV, DPM

With the ever-mounting changes in healthcare and how physicians practice, I wanted to share my experience as a young owner of a private practice. While this may seem like a distant goal, you may be contemplating this type of practice structure. In today’s day to day work environment, it is imperative to know the obstacles you may face. The number of today’s solo practitioners are dwindling in favor of hospital-based employment, multi-specialty groups and/or larger podiatry groups. This could be due to the vast amount of responsibility put upon the doctor. Choosing your electronic medical record subscription, obtaining insurance prior authorizations before office and hospital procedures, navigating treatments around high patient deductibles, and increased in-office overhead expenses could all become daunting tasks. It is no wonder we are seeing reports of physician burn-out at an all-time high. So how does one successfully manage all of these variables and still provide the highest quality of medical care to our patients as a solo practitioner? The answer is simple. Evolve.

Let me explain a bit further. As my father used to tell me, “You can’t know where you are going, until you know where you have been.” As with any practitioner who is seeking advice on how to successfully own a private practice, I always begin with a few questions.

1. How are you generating new patient referrals? Furthermore, how are you keeping your current referring physicians?

There has never been a more competitive time to practice medicine, most notably as a specialist such as podiatry. And many other fields, namely family medicine and internal medicine are feeling a similar burden. The number of hospital-based physician employees and hospital-owned practices are at an all-time high. As a result, some of our best referral sources eventually may no longer be sending us patients if a podiatrist is employed within the same healthcare system. Nurturing referral sources is an important aspect of private practice.

2. Do you have a strong online web presence with positive physician reviews?

Let me give you an example. You are traveling to New Orleans for a conference and a friend recommends a great restaurant in the French Quarter. How many of us are going to search that restaurant on our phones or tablet before making a reservation? Nearly all of us. What if the restaurant had several bad reviews? Would we still go? Some of us probably would not despite our friend’s glowing recommendation. And today’s healthcare climate is no different. In fact, according to Practice Builders, nearly 80% of patients will change their mind about a medical practice after reading a bad review. Patients today are having to pay more money out of pocket for their medical treatment as deductibles rise. It is understandable for patients to be more selective with their physicians moving forward.

3. Do you have active social media engagement (i.e. Facebook, Instagram, Twitter) that is highlighting the strengths of your practice?

The internet has changed the way we all experience healthcare both as physicians and patients. We must evolve and adapt to keep pace with the current digital world. Without a strong online web presence, your practice is going to suffer the consequences. Being active in social media will strengthen the presence of your practice.

4. What criteria are you using to hire your staff, and how are they trained?

“Behind every great physician, there is a great staff.” How is your office staff greeting patients? How are they handling uncomfortable patient situations? Are they courteous and empathetic? Is your software “staff-friendly” regarding scheduling appointments and handling balances?

These are all important questions that every solo practitioner and their staff should be able to answer. Attending podiatry conferences and utilizing the multitude of online resources available will help one stay abreast to the changes that directly affect the practicing podiatrist. The American Board of Podiatric Medicine also serves as a excellent resource and offers access to a vast network of board certified podiatrists that are dedicated to uplifting our profession and offering guidance for private practitioners.

 

ABPM Diplomate, Dr. Stephanie Hook, Elected to the NYSPMA Board of Trustees

Stephanie Hook, DPM

Stephanie Hook, DPM

“I have always had a heart for moving our profession forward. Being elected to the NY State Podiatric Medical Association Board of Trustees is a huge honor and opportunity,” said the newly elected Board of Trustees member, Stephanie Hook, DPM.

As a member of the Board, Dr. Hook will help their mission of supporting excellence in the practice of podiatric medicine and surgery by creating awareness of the profession’s role and value.  This includes supporting lobbying efforts for podiatric related bills, particularly those striving for parity in the medical community, and ongoing work to promote public understanding of podiatry, the level of training required, and specific expertise podiatrists can provide in overall health. She will also serve on the Insurance and Legislative Affairs committees and chair the Awards committee.

Dr. Hook has known since she was a teenager that she wanted to be a podiatrist. “I always knew I wanted to be a doctor, but after having a podiatric procedure when I was in high school and in observing what they did and learning about the profession, I knew then and there that I wanted to be a podiatrist. I know that is pretty young, but I just knew.”

She attended the Ohio College of Podiatric Medicine (now called Kent State University College of Podiatric Medicine) and did her residency at Sisters of Charity Hospital/Catholic Health System in Buffalo.  “I picked my residency pretty much based on the informal conversation I had with the residency director at the reception during the more formal interview weekend. I was the only one at the reception, which ended up being a great way for me to learn a lot about the residency led by Dr. Joseph Anian.  “I remember liking what he said both about the program and life outside the residency.”   For Dr. Hook it ended up being “a great experience.”   “We were part of the program for all residents and were not singled out as the ‘podiatry residents,’ which I have heard can sometimes happen at some institutions.”

Both in school and during residency Dr. Hook was involved in the State Associations and advocating for the profession.  “I think achieving parity and continuing to establish standards for all states is an ongoing process,” stated Dr. Hook, “but one that also needs ongoing attention and support.”

Dr. Hook worked in a podiatric practice for eight years before moving to Syracuse Orthopedic Specialists (SOS), an orthopedic practice near her home in Nelson, NY.   “I love my job,” she says.  “This is exactly the kind of practice I wanted to be part of.  It is collaborative, ethical, we provide our patients comprehensive care, and we treat our patients like they are family.  I love that I can refer cases to other in-house orthopedists and vis versa.”  One of the things Dr. Hook loves best is that this practice has opened her up to a variety of different cases ranging from sports medicine to diabetic foot care to being a part of the Acute Limb Salvage team at St. Joseph’s Hospital.  SOS is comprised of 31 orthopedic physicians and podiatrists, Dr. Hook was the first woman to become part of this practice.  “While I am proud to be part of the group, I don’t like to single out the gender piece, because I am just one of the team.”

Dr. Hook explains that her group is very active in the community providing trainers for local high school sporting events and tournaments, participating in local health fairs where she has been able to lecture about foot health, as well as sponsoring several community events and charities. “It was important to me to be part of an active and caring group,” she explains.

Shortly after completing her residency, Dr. Hook became ABPM certified. “I think it is really important that podiatrists get certified as early as possible because patients and practices are looking for that credential,” said Dr. Hook.  “Nearly every day I hear patients say, ‘I looked you up online and saw that you had your board certification, etc.’ – it’s not just a nice-to-have anymore.”  Dr. Hook selected the ABPM certification because she felt it was the most comprehensive. “In my opinion, it is much more well-rounded and demonstrates your understanding of biomechanics, medicine and surgery – not just biomechanics and medicine as it relates to surgery.”

While Dr. Hook sees the future of podiatry as very promising, she says she also knows there are pockets within all healthcare professions where financial gain can compromise integrity and optimum patient care. She wants to remind all those entering the field that if you do what you love (as cliché as it may sound) the financial rewards will be there – and be there honestly.   This is something she is very passionate about.   “Follow your heart, do what you love, and you will end up doing the right thing for yourself, your patients, your family and your lifestyle,” she shared.  “We are lucky to be in a profession where we can make choices about our day and the kind of life we want to lead.”

Dr. Hook enjoys sports, photography, travel and spending time with her husband, stepdaughter, and three dogs.  She is also proud to be a part of the DPM Mentors Network.  Enjoy more about Dr. Hook in one of the Syracuse Orthopedic Specialist videos.

Clinical Presentation Series: Forming a Differential Diagnosis

By: Dr. Nicole DeLauro, Director, ABPM

A healthy 30 year old male presents with right forefoot pain present for two weeks. The patient is an avid runner, and runs approximately 3 to 5 miles a day. He describes the pain as aching and throbbing. The pain continues throughout the day. He does have relief when resting. He has tried to abstain from running and admits to changing his shoes. He has had minimal improvement. He denies any other treatments.

What is your diagnosis?

As physicians we are forced to be investigators. We have to ask the correct questions regarding the complaint, form a diagnosis, and provide a treatment plan. To do this, we need to formulate a “differential diagnosis.”

The differential is a list of potential diagnoses compiled based on the complaint. It is important not only to determine the best treatment plan but also to treat patients in a timely fashion. The differential helps to narrow down more than one probable cause for the patient’s pain. Your differential can be based on the well known acronym, “NLDOCAT.” What is the nature and characteristic of the pain? Is it burning, shooting, aching, dull, etc? This helps you determine if it’s arthritic, neurological, vascular or musculoskeletal in nature. Once we know which system in involved, focus on the location. What structures are in the area? What nerves, tendons, ligaments, bones, and/or joints are located there? Does it radiate to any surrounding area? The duration of the pain helps decipher if it is an acute complaint secondary to potential trauma or chronic in nature. What makes the pain better or worse? Is it aggravated by activity or rest? Better in or out of shoes? Worse at the beginning or end of day? Does shoe gear alleviate or aggravate the pain? What treatments has the patient tried and has there been any improvement?

Once you have the answers to these questions, the differential is easy to devise. This methodical approach will help you avoid pitfalls and provide better care for your patients. Based on this approach, what differentials do you have in mind? You should be thinking about stress vs. occult fractures, bursitis, metatarsalgia, tendonitis, sprain, and even neuroma. The symptoms can also be aggravated by the patient’s foot type, biomechanical gait pattern,  and even improper shoe gear.  Further questioning, clinical examination, and diagnostic studies will help to lessen the amount of differentials and ultimately attain a definitive diagnosis.

As a young physician, you have the tools to alleviate complaints based on your final diagnosis and gain a patient’s trust and confidence in your care. Your patients will have done their own research before they walk through your door, and expect a certain quality of care. In order to constantly exceed these expectations, you must maintain the highest level of expertise and excellence within the profession. Having  a methodological approach towards your evaluations, and being board qualified and/or certified upholds this level, and informs your patients that you have been tested and challenged extensively within your specialty. This message, when conveyed to patients will solidify their confidence in you as their physician and create a lasting doctor-patient relationship.

Meet New ABPM Executive Director, Dr. James Stavosky

James Stavosky, DPM

James Stavosky, DPM

“Enjoy what you do every day. Be quick to listen, and slow to talk and anger.” These are the words that Dr. James Stavosky, the new Executive Director of ABPM, lives by. He enjoys golfing, fly-fishing and playing tennis with his two sons and his wife (who he refers to as his best friend.) Another thing Dr. Stavosky enjoys? His career in podiatry.

In his 35 years of experience in podiatry, Dr. Stavosky has built an impressive career focusing on wound care. Besides running his own private practice in Daly City, California, he is also the Chief of Podiatric Surgery at Seton Medical Center, the Medical Director of Wound Care at Seton Medical Center, and a Professor of Podiatric Medicine at California School of Podiatric Medicine.

How he found podiatry and how his career took surprising turns

Dr. Stavosky didn’t always know he was destined for a thriving career in wound care. He was first introduced to podiatry during graduate school at The University of the Pacific, where he worked as a student trainer. His advisor at the time “introduced me to her podiatrist, and he set me up to meet and work with some very progressive DPM’s in the area.” From there, he set on a course to study sports medicine.

Later, as a doctorate student at the California School of Podiatric Medicine, Dr. Stavosky got even more involved in the profession. “I volunteered to work on Saturday free clinics every week, and I was a TA for classes,” he says. “Plus, I attended all CME education seminars put on by CSPM—I even volunteered to work AV at those seminars.”

During his residency, even though he initially set out to work in sports medicine, Dr. Stavosky discovered his true passion was elsewhere. “I also developed an interest in foot and ankle surgery, but then found my calling in wound care,” he says.

After completing his residency, Dr. Stavosky worked in academic medicine as a volunteer until he was hired full-time as a professor. He began his career in a full-time position at the Seton Medical Center, teaching four days and tending to private patients two half-days per week.

His career took a turn for the better when he was given the opportunity to take over the wound care department. “No one else wanted to do it, but it put me on the map nationally,” he says. So, from 1987-1998, he was the Department Chair and professor at the Seton Wound Care (Medical) Center.

In 1998 Dr. Stavosky was appointed Chief of Podiatric Medicine and Surgery and opened a full-time private practice.

Board Certification

 Dr. Stavosky was a founding member of ABPM (then ABPOPPM), in 1993. Sitting for this certification was highly important to him, “first for academics, and later for medicine and wound care.”

He is also certified with ABFAS, which he pursued because he “was teaching in the surgery department at CCPM, but in the process realized just how important podiatric medicine was.” He went on to become Chair of the podiatric medical department as a result.

Although the sequence of Dr. Stavosky’s board certifications began with ABFAS, he notes “I would now do it the other way around.”, and advises his students and residents as such.

Teaching the next generation

 In addition to helping patients through his work in wound care, Dr. Stavosky notes that he’s most proud of his experience teaching.

His advice to aspiring podiatrists: “Enjoy what you do, it’s the greatest job in the world. If you don’t want to spend time in a particular facet of podiatry, such as surgery, there’s a tremendous amount elsewhere that our specialty offers, like wound care or sports medicine.”

Along with his academic position he does his best to stay involved in the podiatric community. “I volunteer as faculty for residents and students for both ABPM and ABFAS and am, or have been, on each of their Board of Directors.” He’s also on the Board of Directors at the alumni associations of the California School of Podiatric Medicine and The University of the Pacific. Plus, he lectures on wound care around the country.

What he plans to bring to ABPM

 Dr. Stavosky doesn’t take his latest honor and challenge as the Executive Director of ABPM lightly. He looks forward to “taking our organization, ABPM, to yet another level in the future.  He plans to “guide the ABPM Board of Directors and continue to grow our membership,” along with “getting even more young practitioners involved at the committee and director levels.  With our significant increases in membership, especially over the past five years, we’ve experienced a demographic shift.  We’re getting younger.”

He has ambitious plans, but if Dr. Stavosky’s career proves anything, it is that he is capable of achieving some impressive goals.

Clinical Presentation Skills: Evaluation and Management

By: Nichol Salvo, DPM

When a patient presents in any medical setting for initial evaluation, it is easy to focus on your area of specialty. That being said, having “tunnel vision” may cause you as the clinician to falter. A concerted effort must be made to consider the patient’s co-morbidities that factor into the etiology of their current lower extremity condition. How will this play into the treatment plan?

Consider the following case and the importance of whole patient consideration:

A 68 year-old male presents to the emergency department complaining of increased pain in the right foot with new onset edema and malodor. The patient indicates that pain was his initial symptom which presented approximately three days prior. The patient has a past medical history significant for DM, CKD, stage 3 lung cancer currently treated with chemotherapy, and major depressive disorder. Upon triage, the patient is noted to be febrile at 100.4 degrees Fahrenheit with all other vitals normal. The right foot is noted to have an ulceration to the right sub first metatarsal head with surrounding boggy, necrotic desquamation, heavy with foul odor. The right foot is noted with palpable pulses. The patient denies any knowledge of ulceration to the foot. Labs were obtained by ED staff and the white blood cell count is noted to be 16.1. Radiographs obtained reveal subcutaneous emphysema localized to the plantar medial and plantar central midfoot.

It is clear that an emergent incision and drainage is required to save the extremity. It is easy to get lost in the emergent conversion and transfer from ED to OR. The patient will require consent and it is discussed with the patient that given the circumstances, conservative options are not an option. However, what are the other details that must be considered with the current plan? What other questions will you need to present to your attending?

The patient is diabetic.

  1. What is the hemoglobin A1c? The patient should be advised during the time of consent whether this will impact his outcome.
  2. What is his current serum glucose? Is it elevated and must you consider a concomitant ketoacidosis?
  3. Is the patient NPO? When did the patient last eat or drink and will anesthesia have to be modified?
  4. The patient is on chemotherapy to treat his lung cancer. What are the other pertinent lab values? What are his neutrophils, platelets, hemoglobin, hematocrit, etc.? Based on this review, does the patient necessitate a type and screen in anticipation of a transfusion?
  5. Given his CKD and need for antimicrobial therapy, what is his kidney function at this time? Does your planned antibiotic regimen require renal adjustment to accommodate creatinine clearance?
  6. The patient may potentially require some level of amputation in addition to the planned incision and drainage. Is the patient’s depression managed or should mental health services be consulted to assist the patient in processing and managing the magnitude of what he is facing?
  7. Given his diabetic and malignant state, what is his nutrition status? Have you considered how to optimize his long-term healing by consideration of albumin and pre-albumin?

Having thought of these questions and their answers will not only provide a complete presentation but , also render better patient care. Considering the whole patient when treating the lower extremity is a necessary and critical component of your evaluation and management. There are almost always other things to consider.

 

Explained: Pathology Specific Biomechanical Exam Templates

By: Dr. Stephen Geller, Director, ABPM

Have you ever given someone something you thought would help only to find them using it in a completely unexpected manner? This is exactly what happened when the American Board of Podiatric Medicine provided residency directors with a full-page comprehensive biomechanical examination form. This checkbox form contained hip-to-toe measurements, both non-weight bearing and weight bearing, and in gait. The unexpected outcome was that these forms separated biomechanical examinations from the physical examination performed for most complaints. In reviewing these forms at residency on-site evaluations, there were inadequacies that led to misinterpretations of the examination findings or lack of supporting documentation for the given diagnosis.

CPME 320: Standards and Requirements for Approval of Podiatric Medicine and Surgery Residencies, (the document governing residency programs) contains multiple MAVs, including biomechanical examinations. These biomechanical cases are defined as: “…direct participation of the resident in the diagnosis, evaluation, and treatment of diseases, disorders, and injuries of the foot, ankle, and their governing and related structures by biomechanical means. These experiences include, but are not limited to, performing comprehensive lower extremity biomechanical examinations and gait analyses, comprehending the processes related to these examinations, and understanding the techniques and interpretations of gait evaluations of neurologic and pathomechanical disorders.” At no point does this definition state that a biomechanical examination is from the hip to the toe.

Patient’s present with a specific complaint and not all pathology requires a hip-to-toe examination to be comprehensive relative to the causative factors. Residency training is to impart advanced knowledge so that when in practice, the graduated resident will be able to perform pertinent aspects of the biomechanical examination and identify all contributing factors. This information is used to minimize risk of complications in plan of care. First year residents will be less familiar with the presenting pathology and require more guidance through a more thorough exam to identify those causative factors. A senior resident may require less guidance and identifies all causative factors much faster.

With the development of electronic medical records (EMR), the use of forms that are separate from the electronic documents is increasingly difficult. To bring the biomechanical examination into the physical examination where it belongs, EMR templates for pathology specific biomechanical examinations have been created. These templates consist of: Pes Planus; Pes Cavus; Hallux Valgus; Hammertoe, Lesser Metatarsal and Intermetatarsal Pain; and Proximal Examination. The templates are modular being combined to comprehensively evaluate the pathomechanics of a specific patient. For example, a patient complaining of neuroma symptoms with a low arch would begin with the Pes Planus template and where indicated insert the template for Hammertoe, Lesser Metatarsal, and Intermetatarsal Pain. If at the completion of this examination the findings do not fully explain the pathomechanics of the foot, then the Proximal Examination template is added.

 

 

 

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