Which of the following is an absolute indication for a tonsillectomy?
Correct Answer A:
Absolute indications for a tonsillectomy are:
A 50-year-old woman, who wears high-heeled, pointed shoes, complains of pain in the forefoot after prolonged standing or walking. Occasionally, she also experiences numbness, a burning sensation, and tingling in the area. Physical examination shows no obvious deformities and a very tender spot in the third interspace, between the third and fourth toes. There is no redness, limitation of motion, or signs of inflammation.
Which of the following is the most likely diagnosis?
Correct Answer D: The location and circumstances are classic for Morton's neuroma, a benign neuroma of the third plantar interdigital nerve. Gout happens to obese, elderly males, and redness and signs of inflammation in the affected joint are evident. Hallux rigidus is osteoarthritis of the first metatarsophalangeal joint. There is deformity and limitation of motion. The joint is tender on physical examination. Metatarsophalangeal articulation pain is likewise associated with misalignment of joint surfaces. There is pain when examining the joint, and there is no history of numbness, burning, or tingling. Plantar fasciitis produces sharp pain on physical examination when pressing the plantar surface of the heel.
A 45-year-old white male has a 3-week history of inferior heel pain in his right foot. It has been partially relieved by NSAIDs. The patient, who works as a department store salesperson, describes the pain as throbbing, especially with the first few steps in the morning. It is made worse by walking upstairs. He has no other known medical problems.
On physical examination, the patient is 178 cm (70 in) tall and weighs 128 kg (282 lb). The left foot is normal and the right foot is tender around the medial calcaneal tuberosity at the plantar aponeurosis.
Which one of the following diagnoses is most consistent with this presentation?
Correct Answer B: This case is typical of plantar fasciitis. This condition is more likely to occur in persons who are obese and spend the day on their feet. It typically presents with inferior heel pain on weight bearing, and the pain often persists for months or even years. Pain associated with plantar fasciitis may be throbbing, searing, or piercing, especially with the first few steps in the morning or after periods of inactivity. The discomfort often improves after further ambulation but worsens with continued activity. Walking barefoot, on toes, or up stairs may exacerbate the pain. The patient usually has tenderness around the medial calcaneal tuberosity at the plantar aponeurosis. Although treatment usually includes NSAIDs, no studies have specifically examined the effectiveness of this treatment alone. Tarsal tunnel syndrome presents with pain, as well as a burning sensation and tingling on the sole of the foot. Achilles tendinitis presents with retrocalcaneal pain, Sever’s disease presents as heel pain in adolescents, and subtalar arthritis presents with supracalcaneal pain.
A 55-year-old male presents for an evaluation of heel pain. He has a relatively sedentary office job, but exercises daily by jogging 3 miles. He has pain in the right heel at the medial aspect of the calcaneus and is tender on examination. The pain is worse with the first few steps of the morning. Besides rest, ice, NSAIDs, and prefabricated shoe inserts which one of the following would be beneficial and effective as adjunctive therapy for this patient's condition?
Correct Answer E: Plantar fasciitis, the most common cause of heel pain, may have several different clinical presentations. Patients usually describe pain in the heel on taking the first several steps in the morning, with the symptoms lessening as walking continues. They frequently relate that the pain is localized to the medial calcaneal tubercle. The pain is usually insidious, with no history of acute trauma.
Plantar fasciitis is typically a self-limited condition, and studies have reported a resolution incidence of up to 90% with nonsurgical measures.
Treatment strategies include relative rest, ice, NSAIDs, and prefabricated shoe inserts that provide arch support, as well as heel cord and plantar fascia stretching. Stretching the Achilles tendon is beneficial as adjunctive therapy for plantar fasciitis. Night splints that maintain the foot at an angle of 90 degrees or more to the ankle have recently been used as adjunctive therapy as well.
→ Extracorporeal shockwave therapy (ESWT) has been proposed as a treatment option for plantar fasciitis. Although ESWT has not been definitively shown to be effective, it has been approved.
→ If conservative therapy fails, a corticosteroid injection may be useful. Avoid injecting within the superficial layers of the subcutaneous tissue, because corticosteroid injection into the superficial fat pad can cause fat necrosis and atrophy, which reduce the shock-absorbing capacity of the plantar heel.
→ Surgery, fasciotomy, is reserved for patients refractory to 6-12 months of uninterrupted conservative therapy.
→ Spur removal is not required.
A 70 year old man has had an indolent, unhealing ulcer at the heel of the right foot for several weeks, since he started wearing his new shoes. He indicates that neither the blister nor the ulcer ever gave him any pain. The ulcer is 3.5 cm in diameter, the ulcer base looks dirty, and there is hardly any granulation tissue. The skin around the ulcer looks normal. The patient has no sensation to pin prick anywhere in that foot. Peripheral pulses are weak but palpable. He is obese and has varicose veins, high cholesterol, and poorly controlled type 2 diabetes mellitus.
Which of the following most accurately characterizes the ulcer?
Correct Answer A: Diabetic ulcers typically develop at pressure points, and the heel is a favorite location. The patient has evidence of neuropathy, and the correlation with the trauma inflicted by the new shoes is classic.
Diabetic ulcers tend to occur in the following areas:
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