Always look at their feet!

I clearly remember this advice given to me by a mentor while I was still an internal medicine resident. Though it was several more years before I realized that my calling was endocrinology rather than general internal medicine, I took this admonition to heart.

Simply by asking patients to remove their shoes and socks and examining their feet, over the years I have discovered innumerable foot ulcers, and an occasional gangrenous toe. And yet, it surprises me how infrequently so many of our colleagues perform foot examinations.

Once, one of my patients with diabetes reported being in the ER over a weekend for a swollen red lower leg. He had an ultrasound to rule out deep-venous thrombosis. A presumptive diagnosis of cellulitis was made and he was sent home with prescription of oral antibiotics.

In my clinic Monday, he was somewhat better, but the redness and low grade fever persisted. I examined his feet and found the distinctive shiny head of a deeply imbedded roofing nail. He had severe peripheral neuropathy and was completely unaware. He remembered walking barefoot outside to get the morning newspaper about 10 days earlier. Imaging studies and a surgical consult were arranged. Fortunately, there was no osteomyelitis and he recovered well.

A few weeks ago, I saw a new consult with type 2 diabetes. We had much to talk about and I was running late. Other patients were waiting. She hadn’t taken her shoes and socks off; I almost did not look at her feet at that visit.

When I did the foot exam I was surprised to see shortened fourth metatarsals bilaterally. Examination of her hands revealed a dimple instead of a knuckle over the right 5th metacarpal. Further questioning revealed that as a child she saw a specialist who told her family that her “bones did not grow properly.” No other testing was done and no formal diagnosis was given.

It turns out that several other family members have an identical phenotype. Biochemical testing revealed that this is Albright’s Hereditary Osteodystrophy without abnormality of calcium metabolism or pseudopseudohypoparathyroidism.

I frequently repeat the advice of my mentor to the residents and medical students who rotate with me:

“Always take off your patients’ shoes and socks and look at their feet!”

You’d be surprised by what you might find!