A 63-year old male came to our office on a chilly, but otherwise beautiful, sunny Saturday in Indiana telling staff that he needed a tetanus shot.
“His wife is making him come,” the staff relayed to me as I reviewed the chart and noticed his heart rate was a bit elevated at 102 beats per minute and his blood pressure was below normal at 102/56. I circled the abnormal vitals as these can sometimes indicate infection, cardiovascular abnormalities; or, can be normal for the patient.
I pushed open the exam room door to find an aged patient who appears older than his stated age of 63. His dark-tanned face and white hair contrasted sharply to his wife’s curated appearance. He smiled, creating deep wrinkles on his cheeks and forehead, resembling ripples in the sand of a deserted beach. With irritation and scorn, he pointed to his wife stating, “She thinks my foot needs to be looked at, but I think I just need a tetanus shot, but really, I need to get back to work.”
This kind gentleman related that he was helping a friend fix a barn a couple of days ago when he might have stepped on a nail. “I looked down after I felt a pinch in my foot but didn’t see anything.” He admitted that the barn floor was covered in debris including nails, dust and manure. His wife stated that he never goes to the doctor but she didn’t want him getting tetanus.
The patient said he had no pain with walking or difficulty with activities of daily living. When the patient removed the sock of his left foot, I immediately noticed a purplish, gray second toe and surrounding redness of the first and third toes. All toenails were yellow but this was normal per the patient. The redness extended up both surfaces of his foot stopping just below the tarsal bones at the ankle. There was a small puncture wound on the sole of the foot a couple of inches from the second toe. No drainage from the puncture wound nor pain during palpation of the foot was appreciated, even though his foot was slightly warm to touch.
For comparison purposes, I examined the other foot and again noticed yellow toenails, but without any toe discoloration or redness. He was able to move both feet and toes appropriately without any difficulty. He couldn’t feel me touching any surfaces of both feet. This always raises concern for diabetes or another disease that can affect neurovascular supply. I discussed with the patient and wife that I would order x-rays to exclude any foreign bodies, including nails, and obtain a blood glucose level using an in-office glucometer.
While waiting on x-rays and labs, the staff informed me that his blood glucose was 211, which is elevated and likely indicates he is an undiagnosed diabetic. This definitely raised a few more red flags in my mind. I made a mental note to inquire further about his medical history after reviewing his x-rays. A few minutes later, there was anxiety in the x-rays tech’s usually calm demeanor when he said the x-rays were ready to view.
From across the room, one was able to see a large nail imbedded deep in the soft tissues of the foot. On the second and third view, the nail was curved and appeared to have wedged itself between the second and third metatarsals just above the toes. When I walked back into the room to explain this to the unpresuming patient and wife, they both screamed in utter disbelief. I explained to them that he will indeed need a tetanus booster and to go immediately to the ER for surgical removal of the nail and IV antibiotics.
I also informed them that his blood glucose was elevated and it was likely he was diabetic. This will eventually need further evaluation in the hospital and by a family physician. It is normal practice for diagnosed diabetics to have a family member or themselves check their feet daily to exclude infections or open wounds. In diabetics, the body cannot process sugar and other metabolic processes correctly, thus negatively impacting nerve and vascular supply to distal and small vessels of the body such as the feet, hence the reason he couldn’t feel me touching his feet earlier.
Prior to the TDaP (tetanus, diphtheria, and pertussis) administration, I again asked the patient about any other medical illnesses or surgeries he might have forgotten to disclose. “Oh yeah, I have a fake valve in my aorta.” This raised the hairs on the back of my neck. I immediately listened to his heart sounds and noticed a cardiac murmur with accompanying hissing sound. I could also hear these sounds in his neck. Not knowing if this was the patient’s normal heart sounds after his aortic valve replacement or if this was new since he stepped on and implanted the nail in his foot, I called the ER again to update them on this finding as this is now a true medical emergency. Infections from other parts of the body (nail in the foot) can spread to and seed themselves not only on our own heart valves but transplanted valves increase these chances even more. If left untreated, these valvular infections can lead to heart failure and eventual death.
The patient subsequently underwent surgical removal of the nail by an orthopedic surgeon several hours after being seen in our office. He was started on IV antibiotics for his foot as well as for the valve in his heart. The patient’s heart valve had not been infected, but he continues to receive IV medications just in case and routine cardiac ultrasounds and monitoring to assess the overall health of his aortic valve.
Misconceptions of a slight pinching sensation in one’s foot to a slightly discolored lower extremity can be easily confused between simple medical conditions to more ominous, sometimes life-threatening emergencies. The above situation is a clear demonstration of this. Patients and family members can also learn from the above scenario and be an advocate for obtaining an evaluation by a medical professional to ensure that the patient receives appropriate medical care as needed. If a limited physical exam was performed, the patient and patient’s representative should not be hesitant and ask why a more detailed exam isn’t being performed. One could have just as easily looked at the gentleman’s foot and ordered a tetanus vaccine without further history taking nor exam being performed. This situation likely would have proceeded from bad to life-threatening without further for the wife forcing the husband to come to our clinic for further evaluation.
There are subtle differences between symptoms, history, and physical exam that can aid in the correct medical diagnosis. So, when feeling ill or injured or just concerned about your or a loved one’s health, it is best to be evaluated by a medical professional as quickly as possible. Safety first.
Post by Mark Hannaford, physician’s assistant for U.S. HealthWorks in Muncie, Indiana.