Chapter 41: The Foot and Ankle

Multiple Choice Question 1 of 6

1. Question

A patient with diabetes presents to the Accident and Emergency Department with a hot swollen foot with no breaks in the skin. How should this be managed?

Scan for a deep vein thrombosis (DVT). If negative, send the patient home
Treat with antibiotics and ask the GP to review in 48 hours
Diuretics and compression stockings
Refer to the diabetology/foot clinic in 6 weeks' time
Follow the National Institute for Health and Care Excellence (NICE) guidelines. Arrange imaging and immediate review by the team responsible for diabetic foot emergencies, offload the foot and admit the patient if necessary

Multiple Choice Question 2 of 6

2. Question

A patient with diabetes presents to the Accident and Emergency Department with a swollen foot with a small superficial ulcer following an insect bite 2 days previously. How should this be managed?

Antibiotics and ask the GP to review in 48 hours
Advise the patient to go home, rest, elevate the foot and return if there is no improvement in 48 hours
Arrange for review in the diabetic foot clinic in 6 weeks' time
Give the patient s tetanus booster and antibiotics and review in 1 week
Follow the National Institute for Health and Care Excellence (NICE) guidelines. Arrange imaging, bloods and immediate review by the team responsible for diabetic foot emergencies, offload the foot and admit the patient if necessary

Multiple Choice Question 3 of 6

3. Question

A 40-year-old man felt his ankle give way 3 weeks ago running at soccer and now has calf pain and is struggling to run or climb stairs. On examination by you in the Accident and Emergency Department, he has no Ottawa signs around his ankle but has a swollen calf. You send him for a deep vein thrombosis (DVT) ultrasound scan, which comes back as negative. His Simmonds test is weakly negative (normal). What do you do now?

Reassure him and send him home. Tell him to return in 4 weeks if no better
Provide an ankle brace, physiotherapy and review if no better in 6 weeks
Be aware that any clinical signs for an Achilles rupture are invalid at 1 week, especially if the plantaris is intact. Rescan the patient's Achilles tendon looking for a rupture
Assume that the scan was wrong. Start the patient on apixaban and arrange for a rescan in 6 weeks
Tell the patient that the Accident and Emergency Department is not a place for chronic problems and ask him to see his GP

Multiple Choice Question 4 of 6

4. Question

A patient presents with plantar fasciitis and is really struggling with low back pain that he thinks is secondary to his limp. He struggles with anti-inflammatories because of psoriasis and his foot is so sore even his toes are swollen and painful. How would you manage him?

Advise that plantar fasciitis takes months to settle. Give him an advice sheet, a soft heel pad insole, stretching exercises and ask him to attend his GP in 3 months if it has not settled
Book him in for an ultrasound-guided injection of steroid or shockwave via the foot clinic for his heel pain
Book him a magnetic resonance imaging (MRI) scan of his spine and refer him on
Prescribe anti-inflammatories and tell him a foot clinic is not the place to discuss back pain. Ask him to see his GP to arrange a spine appointment
Suspect that he has a seronegative arthritis, arrange an urgent review by rheumatology with imaging and bloods in the meantime

Multiple Choice Question 5 of 6

5. Question

A 22-year-old Army recruit has pain in his instep (with flat feet) that really is stopping him from running. He does not want anyone in the Army to know in case he fails to complete selection. He can single-leg tiptoe and he retains full power of inversion but he is sore in his midfoot. How would you manage him?

Assure him that no one will know, give him some non-steroidal anti-inflammatory drugs (NSAIDs) and tell him to give it a few weeks
He has very flat feet so tell him to get some insoles
Advise him that, with his feet, he would be better joining the Navy so that he can just sit around on a boat all day or join the RAF so that he can be checking in while the Army are digging in.
Ask him to see the base physiotherapist for some exercises and re-present to the Resident Medical Officer if not better in 6 weeks
Recognise that a high proportion of military recruits suffer stress fractures and that a navicular stress fracture is a strong possibility here. Immobilise, arrange a magnetic resonance imaging (MRI) scan urgently and, if positive, do a metabolic bone work-up

Multiple Choice Question 6 of 6

6. Question

A 45-year-old woman presents with a persistent ulcer on the sole of her foot over her metatarsal heads that she has had debrided by the podiatrist for years. It came on after she had trodden on a piece of glass 5 years before. What do you do?

Refer her back to podiatry for offloading insoles
Arrange imaging to exclude a retained foreign body or bony anatomical abnormality and then biopsy the skin edge to exclude a malignancy. Check her for neuropathy and diabetes, and put her into a total contact cast with weekly reviews until the ulcer has healed or undertake surgery if there is a correctable abnormality
Give her an antifungal cream and ask her GP to review in 6 weeks
Give her advice not to wear high heels and ask her to see her GP in 3 months if it is not better
Send a note to her podiatrist to try and do a better job of debriding it

Chapter 41 The Foot and Ankle

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