A 78-Year-Old Woman Comes to the Physician with a Red

question 708

Multiple Choice

A 78-year-old woman comes to the physician with a red and swollen right foot for the last 2 weeks.  She also reports mild pain that is relieved with acetaminophen.  There is no associated fever, chills, or morning stiffness.  She has not fallen or had trauma to the foot.  The patient's other medical problems include coronary artery disease, hypertension, and type 2 diabetes mellitus complicated by peripheral neuropathy and chronic kidney disease.  Her medications include aspirin, lisinopril, metoprolol, insulin, and gabapentin.
Vital signs are within normal limits.  Her body mass index is 32 kg/m².  Examination shows warmth, erythema, and edema to the plantar surface of the right foot.  There is a visible collapse of the arch of the right mid-foot.  No skin ulcers or sinus tracts are present.
X-ray reveals advanced degenerative changes with dislocation of the mid-foot.  Fluid aspiration from the right tarsus shows 200/mm³ red blood cells and 200/mm³ white blood cells (60% neutrophils) .  No crystals are seen and the Gram stain is negative.
Which of the following is the most appropriate next step in management?

• A)Casting with avoidance of weight bearing
• B)Orthotic shoe inserts
• C)Physical therapy
• D)Sulfasalazine and acetaminophen
• E)Surgical intervention

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