Case report: Double trouble

At our walk-in clinic, we are presented a variety of problems, many related to recent injuries. There are lessons to be learned from each encounter. Usually, I see a patient with an issue which has begun a day or two prior to the visit requiring urgent care, and the patient unable to make an appointment with their family physician within a reasonable time frame. But occasionally, the reason for a visit is more complex.We were called in advance by a woman asking if I could remove stitches from her mother. Her family doctor was far away and unavailable. Since the stitches were reported to be on her mother’s foot, I agreed. The patient arrived shortly thereafter—an 83-year-old woman, accompanied by her daughter. The patient was tall, mobile and healthy with no allergies or underlying illness and taking only blood pressure medication. When her foot and lower leg were exposed, the problems were much worse than expected. Two weeks before the visit, the patient had fallen from a deck onto garden furniture and a cement patio. Bleeding profusely from her toe, she went to Emergency, where her foot was sutured, with no advice regarding wound care or follow-up. After the two-week interval, the patient and her daughter decided that they needed more input.Examination revealed several major problems. The original bandages—never touched—were loosely in place, with oozing and swelling beneath. Removal of dressings revealed a sutured foot (visible in picture) with buried sutures, dead skin flap and erythema. Her lower leg (also bandaged but untouched) revealed a large, swollen, blackish abrasion with oozing and inflammation (also hopefully visible in picture) extending down to the ankle. Fortunately, the heavy sutures were visible (but should have been removed before). I removed the sutures, leaving a gaping wound. I felt that both areas of injury were infected and treated with oral Clavulin and Fucidin cream to be applied under loose gauze dressings. Elevation of the leg and follow-up with the family doctor (and possibly wound care) were recommended.Once again, lessons arose from the scenario. Avoiding falls to which older patients are prone, ensuring that adequate follow-up instructions are received following initial care (even though the hospital was busy) and re-evaluation of the injuries (with suture removal) at a shorter interval, should have been essential. The patient and daughter were very grateful following a rather prolonged visit and recommendations for follow-up.Dr. Robert Dickson is a family physician in Hamilton. This report is based on a real case from Dr. Dickson’s files.

Case report: Double trouble

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