FOOT PAIN - GENERAL MEDICINE 1329

Abstract

HISTORY: 37 year old female presented with acute atraumatic onset of right foot pain and swelling. She reported the pain began over the first metatarsal of the foot and then spread to include the entire dorsal aspect of the foot. She presented three days after symptoms began, stating that she was unable to walk secondary to extreme foot pain during both mid-stance and terminal stance phases of gait. Advil provided her with minimal relief. A one week course of range of motion and strengthening exercises provided minor relief. She reported no fever or rashes, but does admit to previous bilateral hand pain for which a Lyme's disease and rheumatologic work up were negative either months prior. PHYSICAL EXAMINATION: Well developed, well nourished white female in no acute distress. Foot revealed no erythema, edema, ecchymosis atrophy or increased warmth. Range of motion was normal. Pain was present to palpation of the metatarsal heads for digits one, two, and three, as well as tenderness to palpation of the extensor digitorum longus tendons for the same digits. Pain was present with dorsiflexion and plantarflexion of digits one, two and three. No swelling was present. Strength and sensation was normal. Anterior drawer was negative. Gait was antalgic favoring the right lower extremity with a decrease in time spent in terminal stance phase. No other joints displayed erythema, warmth, swelling or tenderness. Initially, the patient was provided with crutches for NWB, ROM exercises, icing and antiinflammatory medication. DIFFERENTIAL DIAGNOSIS: Extensor digitorum longus tendonitis Rheumatoid arthritis Lyme's disease or other inflammatory arthropathy Cellulitis Fracture TEST AND RESULTS: AP, lateral and oblique views of right foot: Negative for fracture or soft tissue swelling. Minimal degenerative changes seen. AP, lateral and oblique views of the bilateral hands: No joint erosions, arthritic changes or soft tissue swelling. Lyme's titers: Total Lyme antibody by EIA: Equivocal - 0.98,(0.0-0.89 = negative), IgM Lyme's titers by EIA: High - 1.87, (0.0-0.89 = negative), Lyme antibody P41 present Rheumatoid arthritis titers: Negative Antinuclear Antibody; Negative FINAL/WORKING DIAGNOSES: Lyme's disease TREATMENT: Administer pregnancy test - if negative, begin antibiotics Doxycycline 100 mg. per os twice per day for 30 days Antiinflammatory medication at 800 mg. per os tid with meals. HVGS, ice, stretching. Active ROM as tolerated. Return to sport specific activities as tolerated and dictacted by therapy program.