Sunday, June 15, 2008

Advanced Diagnostics

(Ring. Ring)
On-call Doctor: So what's the trouble you're having?
Assistant Village Idiot: I may have broken a small bone in my foot. I was up on a stepstool, working on a ceiling, and I slipped and came down hard on it. Then I was up and down on the stepstool quite a bit after that.
OCD: Is there any pain?
AVI: Only when I put weight on it. It ached a little last evening, but I didn't have a lot of pain until I got up in the middle of the night. I can't put weight on it.
OCD: So, no specific accident, then?
AVI: Not other than the fall, no.
OCD: It could be an episode of gout.
AVI: I'm pretty sure it's not gout. I was up and down on the foot a lot yesterday.
OCD: It could still be gout. You can take Advil for the pain.
AVI: I don't have any pain, except when I put weight on it.
OCD: Well, take Advil for the pain, three times a day with meals.

This is not the beginning of a comedy routine. This is this morning's phone conversation.

I haven't been to med school, but I'm thinking this would be a fairly atypical presentation of gout. I'm hoping reader Giacomo, an orthopedic surgeon, will back me up on this.

So at the walk-in clinic after church, I repeated my delivery of "I may have broken a small bone in my foot, but if I'm lucky it's just a sprain" to five different people there. None of them suggested gout, so I didn't bring it up myself. The X-Rays looked okay, except for some bone chips from a long-previous ankle injury. Probably just a sprain.


Anonymous said...

Maybe you should see if you can get a Purple Heart, just like John F Kerryman.

I found it amusing that he got those medals for wounds that were less grievous than some of the injuries I incurred playing pickup football and soccer in my younger years.

One would have thought that all the doofuses would have been already screened out of the medical profession, considering how hard it is to get admission to medical school.

Anonymous said...

This is the strangest consult I've ever given.

There were two primary possibilities when you first injured it. Ankle sprain, inversion type, or avulsion fracture of the base of the fifth metatarsal. Both would allow you to resume going up and down the step stool but with some pain, and would be worse the next morning. (Witness Rajon Rondo playing on a mild sprain.)

Obviously there are other things that could have happened (differential diagnoses), and gout does make the list, but not very high up. Midfoot sprain, Lisfranc fracture, syndesmosis sprain, ruptured tendon, muscle sprain, etc., depending on where it hurts, where it's tender, and where it bothers you with use and/or stress. BTW, it still could be a fifth MT avulsion if the xrays were ankle films, not foot, and didn't show that area.

Generally a physical exam is required to be certain, but if it's one of the two primay possibilities you'll recover with ice, relative rest and protection from further injury, and the occasional ibuprofen.

Was "on-call doctor" an orthopod?

Anonymous said...

I have found doctors to be notoriously poor diagnosticians. I don't know why that is, but it generally seems to be the case.

Assistant Village Idiot said...

I am assuming the on-call doc was Family Medicine or an internist, as it was my PCP's office I was calling.

Just a touch twinge-y today, so sprain seems most likely. I'll be doing stupid things again in no time.