FEWA member, Philip J. Obiedzinski, DPM, shares his case study in this issue’s Member Editorial Corner. Philip graduated from St. Peter's College in Jersey City with a BS in biology then attended the New York College of Podiatric Medicine where he completed a two-year residency in foot surgery. He is Board Certified in Foot/Ankle Surgery. He has been published in several podiatry journals and has attended many clinical conferences.
A 49-year-old mother of a young child presented to a podiatrist in August of 2013 with a painful "lump" on the bottom of the ball of her foot; two months' duration. She had scraped it herself. Otherwise, there was no other professional or self-treatment. She complained of a "callus" with a black dot. On examination, there was resisted plantar flexion of the second toe. She exhibited a long second metatarsal with pain below the second metatarsal head. The diagnosis was tenosynovitis and hemorrhagic keratosis.
The podiatrist did not elicit a history of trauma, new shoe gear, new activity, nor standing/exercising to account for the “hemorrhage”. A follow-up visit was recommended, as necessary. On 1/15/14, the lesion was still present. The podiatrist debrided the area. His notes state that it was debrided as at the previous visit, but the previous notes do not contain any information on debridement. The podiatrist noted "organized hematoma, previous abscess." There was no drainage. The area was debrided. "A hematoma was evacuated." The podiatrist recommended an insole and follow-up in one week. On 1/22/14, the podiatrist noted that the lesion was better with debridement and he again removed additional organized hemorrhagic material. He applied padding to an insole.
Two weeks later it was noted that the lesion was between the metatarsal heads. Therefore, this was not a pressure-related lesion. It was discolored, linear and with an organized "hematoma." There was pinpoint bleeding centrally. In two weeks, there was no change in discoloration and a biopsy was recommended. This was done two days later. The diagnosis revealed a deep malignant melanoma, which eventually became metastatic and the patient later succumbed.
During her videotaped deposition, which was expedited anticipating her demise, she brought in pictures of her daughter to be noted in the record. The patient stated that the black color in the lesion never resolved at each visit in contrast to what the podiatrist stated during his deposition. He stated that after each debridement the area was clear of discoloration.
My opinion was for the plaintiff. In my opinion, there should have been a differential diagnosis at the initial visit, which included a malignant melanoma. Without history of trauma or change in activity/shoe gear, there was no etiology for traumatic hemorrhage. Five months had passed between initial and subsequent exams. In my opinion, the podiatrist at the initial visit should have requested a follow-up visit in approximately two weeks to check the lesion and then biopsy if there was no change.
The case settled after my report and before my deposition.
Philip J. Obiedzinski, DPM