Rashes & bumps... What to do when you're just not quite sure.

As an APRN that specializes in foot and ankle conditions, I face a very similar clinical reality as my colleagues in primary care... Disorders of the skin.  The skin problems that I most often see are related to fungal infection and warts.   But every once in a while I am presented with a much more interesting and unique dermatological challenge.  In fact, I will present to you a patient case that just happened last week.

A 10 year old caucasion female is referred to my by her pediatrician for "wart removal" of a solitary plantar wart on her plantar medial heel that has been evident for the past 3 months.  The lesion grew over a section of skin that her mother said previously had a birth mark.  The lesion measured 6mm in diameter and was raised.  It had a pink-brown pigmentation and the borders of the lesion were smooth.  It did not have a rough "warty" appearance.  After taking a medical history and evaluating the lesion, I recommended that we biopsy the lesion.  I choose to do a simple 2mm punch biopsy (after numbing under the lesion with a marcaine with epinepherine mixture).  I sent the specimen to my Dermatopathologist, BAKO Pathology and 2 days later had a diagnosis... Spitz Nevus.  I referred this patient to my partner, Dr Paul Krestik, for a complete excision of the lesion. 

Spitz Nevus (Click for video information) 

Additional Information on Spitz Nevus

I believe that there are at least two major take home messages from the case above.  First, as APRN's we need to biopsy more lesions.  Why send our patients out to dermatology for biopsy when it can be simply and effeciently done in our own office?  Second, an excellent Dermatopathologist is a very important member of your clinical team.  After trying several different pathology companies in my practice, I have concluded that BAKO Pathology is the premiere. 

If you are not comfortable doing simple punch and shave biopsies in your office, I would challenge you to find a continuing education course on the topic and gain some confidence and skill in this area.  I will do a brief educational primer on these techniques in the near future.

You've got to know your anatomy...

One of the most important aspects of being an excellent clinician is simply knowing human anatomy.  As advanced practice nurses, we spend many years in school and clinical practice becoming experts in diagnosing and treating a wide variety of health systems.  However, I find that with many primary care providers, APRN's included, often do not devote enough "educational energy" on the foot and ankle.  The human foot and ankle is a complex mechanical structure containing more than 26 bones, 33 joints (20 of which are actively articulated), and more than a hundred muscles, tendons, and ligaments.^[1]   



Foot and Ankle Anatomy Resource

Considering the variety of conditions that manifest in the foot and ankle, it is essential to become a competent clinician in this arena and that will involve an investment of time and energy.  Is it worth it?  Absolutely.  Musculoskeletal conditions of the lower extremity comprise a significant percentage of patient encounters in primary care.  As a nurse practitioner, I am acutely aware that our patients trust our judgement and look to us as their health care expert.  Although I realize that it is impossible to become a highly skilled specialist in all facets of health care, it is our responsibility to continue to grow and learn as providers.

How many hours over the past year have you invested in studying the anatomy of the foot and ankle?  Have you been to any continuing education courses on this topic?  Are you willing to put the "educational energy" into learning a new area for your clinical practice?

If so, I would recommend that you start off by simply doing an online search for anatomy of the foot and ankle.  You may find an additional excellent online resourse HERE.