Foot 1:
A year or so after we opened our doors, one of our neighbors- a now 86yo lady who lives just down the hill from us- presented for evaluation of a spot on her foot.
Our patient attributed this skin lesion to having "stepped on gum at the market." I encouraged the patient to have an excisional biopsy to evaluate for more serious pathology beyond gum at the market. She was agreeable.
I performed a wide local excisional biopsy of her skin lesion. This was facilitated by ultrasound guided posterior tibial nerve block (providing excellent anesthesia to the plantar surface of her foot). The pathology report confirmed my suspicion of malignancy -specifically, ACRAL MELANOMA- but also indicated ALL MARGINS FREE OF DISEASE.
Pathology report:
Our neighbor is still alive and well.
Foot 2:
Last week a 44yo male patient presented with a chief complaint of shortness of breath. Ultrasound evaluation revealed large bilateral pleural effusions.
(Note: the black area to the left of the screen on the ultrasound clip is pleural fluid. The patient's lung appears intermittently in the lower left corner of the image. Diaphragm with irregularity to right of screen)
As our patient was experiencing significant respiratory distress -with a rapid respiratory rate, increased work of breathing, and inability to sleep for several nights- a therapeutic thoracentesis was performed. More than one liter of fluid was drained from the left side of his thorax.
After consideration of some of the usual suspects (infection, renal insufficiency, heart failure, etc.), no obvious cause of the patient's pleural effusions was initially identified.
He then mentioned a spot on his left foot.
His left leg was quite swollen. He had markedly enlarged lymph nodes in his left inguinal area. He attributed his leg swelling to having "stepped on a thorn a few months ago." Examination of his foot revealed an irregular skin lesion. Punch biopsy was performed. Pathology results are currently pending. However, I strongly suspect he has advanced skin cancer with spread to lymph nodes and thoracic cavity. I fear his prognosis will be much less favorable than the owner of "foot 1."
Had our second patient been evaluated and treated several months ago when his skin lesion first appeared would the trajectory of his illness and ultimately his life and the life of his family (who are dependent on the income he generates working on a farm in the area) be different? It is impossible to know for sure, but I certainly believe so.
Our "tale of two feet" further demonstrates the importance of timely access to appropriate care.
top photo by Danie Franco on Unsplash