Residency Insight -- A PRESENT Podiatry eZine

Volume 4 - Issue 17

Guest Editorial: For Tonight's Residency Insight piece, I would like to bring to you a previous contributor to PRESENT Podiatry, Dr. Sarah Fitzgerald, who is the medical director at the Hess Lower Extremity Wound Care Center in Harrisonburg, Virginia. Tonight, she presents an interesting case of a 25-year-old male who presents with unusual lesions along his bilateral lower extremities. Please read below for the detailed case presentation.

—Ryan Fitzgerald, DPM, PRESENT RI Associate Editor

Case Presentation: 25 y/o with Recurrent Abscess Formation
and Skin Lesions

Dr. Sarah Fitzgerald
Medical Director
Hess Lower Extremity Wound Center
Harrisonburg, Va

HPI: The patient is a 25-year-old male presenting to the office complaining of two red, hot, and painful raised lesions that are located on his foot and along his lower leg. Currently he rates severe pain at 10/10, and states that he is in so much pain, that he would like me to drain the lesions here in the office today. The patient’s primary care physician has recently seen this patient and prescribed courses of both keflex and bactrim with no resolution of the patient’s symptoms. The only drug that temporarily relieves the patient’s pain is vicodin, which the patient’s primary care physician has also prescribed for him. The patient then admits that on several occasions he had lesions like these in the past and that he has treated them himself by lancing them open. Previously, when he has performed this procedure, he relates that once he opens them, the lesions drain clear fluid, then slowly resolve.

PMH: Unremarkable PSH: None

MEDs: Vicodin prn for pain ALL: NKDA

Vitals: T 98.6 P 80 R 20 BP 140/ 80

PE: The patient is a 25-year-old male who stands 5'3" and weighs 150 lbs. He has a very frail and petite body habitus. He is awake, alert, and oriented x 3, and appears in notable distress. A focused lower extremity exam reveals multiple sharply circumscribed brownish red plaques on the anterior, medial, and lateral surfaces of the bilateral lower extremities. On the patient's lateral right leg and in the area of the hindfoot, there are two very tender fluctuant nodules with surrounding localized erythema that do blanche with pressure. These areas demonstrate the greatest location of the patient's symptoms — he does not appear to be tender along the remaining areas of the plaques. The patient is neurovascularly stable with appropriate palpable pedal pulses; sensation, proprioception, and vibratory sensation is intact along lower extremity nerve distributions bilaterally. Muscle strength is within normal limits.

Following a bedside incision and drainage of the lesions, how would you continue to manage this patient? What pearls can you share with our online community regarding your experiences in the management of challenging dermatological issues?

Considering the clinical findings, history described and image above, how would you proceed in the management of this patient? Share your thoughts, pearls and experiences the e-Talk forum on this topic.