How to provide and take a great history so that a more accurate diagnosis is reached

I usually follow the NLDOCATS routine when talking to a patient Nature Location Duration Onset Course Aggravating factors Treatments Special/Other Always start by writing the Age and Gender.

Example: Joe is a 34 year old male who complains of...

Nature: What is the problem? Example: ankle fracture, foot pain, leg pain, toe pain, nerve pain....

Location: Be as precise as possible: Medial/Lateral, Left/Right, Dorsal/Plantar, name of tendon

Duration: How long has this been going on?

Onset: Was there any recent trauma? Did you just wake up with it? Was there a history of prior injuries or pains?

Course: Getting worse, better, same? 

Aggravating factors: What makes it worse? What makes it better?

Treatments: Has anything at all been tried? Medication, splints, braces, therapy, other doctors? 

Special/Other: Change in activities? Shoes? Run more? Run faster? Really anything else to fill in the gaps of the story.

This is a great way to obtain a detailed history.

Joe is a 34 y/o male who presents c/o pain in the left foot at the 3rd interspace. Feels like a sharp pain that radiates to his 4th and 3rd toes. Sometimes he notes a clicking. The pain has been present for about 6 months. Denies any history of injury. It has been getting worse the last few weeks. Pain is relieved with rest. Notes that he has increased running lately. Has been doing more business meeting in a dress shoe. Has tried Motrin with no relief of symptoms. Has not seen a doctor in the past. Diagnosis? Most likely a neuroma.

Buy PediFix ShoeZap Ultraviolet Shoe Sanitizer at a great price

PediFix ShoeZap Ultraviolet Shoe Sanitizer

UVC germicidal light kills fungus and bacteria that thrive in shoes and cause Athlete’s Foot, toenail fungus (onychomychosis), foot and shoe odor, skin infections and more. Helps keep shoes ‘microscopically clean’, hygienic and odor-free, without the use of toxic chemicals. 15-minute automatic-off time cycle.

Place Sanitizers in shoes. Place shoes & Sanitizers in UV-proof safety bags. Power 'On'. Device turns off automatically after 15-minute treatment.  

$124.99 / Pair

Steri Shoe

Bunion Splints and Sleeves as a conservative treatment for Bunion Pain

There are a variety of bunion splints on the market.

The goal of a bunion splint is to pad the painful areas. Some patients will try and wear them to correct the bunion deformity before considering bunion surgery.

If you take the concept of braces for your teeth, a bunion splint works the same way. The main problem with bunion splints is the amount of time they are worn.

If you spend more time outside of the splint than in it, the product will not work.


Darco Bunion Splint

Helps to keep your toe straight after bunion surgery!

The soft but sturdy construction of this splint allows for maximum comfort, while splinting the big toe in a straight position. Gently stretching the soft tissues around the big toe joint helps prevent the bunion from returning after surgery. We have found that this splint may help to provide added insurance for a good post-surgical result. Wearing this splint after surgery may also help to control swelling

Dr. Jill's Gel Bunion Sleeve

Features of Dr. Jill’s Gel Bunion Sleeve:

• Soft tan satin fabric.
• Cushions and protects the painful bunion.
• It's large soft gel pad protects the bunion from shoe pressure.
• The cushion conforms to your foot and does not create bulk in your shoe.
• Universal – provides a comfortable fit on either foot.

PediFix Soft Bunion Splint (Hallux Valgus SoftSplint)

Features:

• Designed so that this splint can be worn comfortably, whether you are weight-bearing or resting.

When used after bunion surgery, this Bunion SoftSplint: 

• Helps to maintain ideal positioning of the big toe.
• Constant metatarsal-phalangeal joint alignment.
• Helps control swelling.
• Offers post-operative security to the surgical site.
• It is constructed of thin, light-weight, comfortable, and durable materials. 
• The SoftSplint is washable.
• Velcro fasteners makes adjustment and application of the splint simple and easy.

PediFix GelSmart Toe Spacer -- Bunion Guard Combo

Bunion cushion and toe separator in one!

• The contoured gel bunion shield (pad) helps minimize friction, pressure, and bunion pain when in shoes, while the soft toe spreader gently provides proper toe alignment to help prevent the 1^st and 2^nd toes from rubbing. 
• Made of Visco-Gel that stretches to fit your foot and slowly releases medical grade mineral oil (USP) and vitamin E which soothes, softens, and moisturizes skin. 
• Washable and reusable.

How It Works:

Soft Gel Spacer separates and aligns first and second toes that rub, while the contoured Gel Guard cushions and protects the bunion. Original Visco-GEL® slowly releases medical grade mineral oil (USP) and vitamin E which soothes, softens, and moisturizes skin.

Features:

• Eases buinion pain - cushions, protects, and soothes, painful bunions.
• Absorbs pressure and friction.
• Separates 1st and 2nd Toes.
• Washable and reusable.
• One size fits all.
• Fits right or left foot

Ball and Ring Shoe Stretcher

This easy to use bunion stretcher allows you to stretch the specific part of your shoe causing pain rather than stretching the entire shoe. This device can stretch problem areas without stretching the entire footbox.

Directions: 

• Determine the area needed to be relieved.  
• Place a Zip Lock bag over the shoe to protect the exterior finish. 
• Place the ball inside the shoe with the ring on the outside. 
• Press the arms of the Stretch together over this problem area of the shoe. 
• You should see immediate results, with your shoe fitting more comfortably.  
• Can be clamped on overnight for especially difficult areas

Please feel free to post any questions.

Advice for Podiatry Third Year Residents - Senior Residents

Yes, it is true that this is when you have the most amount of academic knowledge. What you don't have is real patient experience.

You are probably thinking about looking for a job or doing a fellowship.

I did both when I finished my third year at UMDNJ. I ended up doing a fellowship in Sports Medicine and Surgery of the Foot and Ankle in Irvine, CA.

The main reason I did a fellowship was because I wanted to obtain the highest level of education possible for my field. I am now in solo practice. I started out as an associate and am now a partner in the process of purchasing out the practice.

I'll try and go over the main things to look for when considering both.

Let's start with a job. The most important thing to ask is where will this job lead? Do you have the ability to become a partner? How much will it cost you to become a partner? How long will you be an associate? There are of course lots of other questions, but the ones I stated should be the main focus.

Maybe you don't want to have your own practice and would like to work for someone. The main things to consider there is can you live in the area? Will your spouse agree? Is the patient flow what you want? What are the benefits? Salary, vacation, sick time, 401k, car, bonus...

What should a first year associate make?
This all depends on the volume of patients you see. Your salary can range from $70,000 to $160,000 first year out. There should be a bonus clause in there. Let's say you agree on a $100,000 salary. The bonus can kick in once you collect a revenue of $250,000 at a percentage. The percentage is between 5%-50%. So, let's say for the year you collected $300,000 and your bonus percentage is 20%. You will make $110,000 for the year. Keep track of your patients and the EOB's

Taxes?
Are you an independent contractor or employee?

Starting your own practice?
This is very doable for the entrepreneur physician. I have lot's of experience with that if you have questions. My knowledge is in California, but it applies to most states.



Fellowship

When considering a fellowship, you must think about the step after. Do you want to do the above or work for an academic center? If you want to do the above I would highly advise on doing a fellowship in an area you are interested in settling down in. This will make your job search later on much simpler.

If you want to teach at an academic center then you should do a very specialized fellowship. Diabetic Limb salvage is usually the top choice.


Please feel free to post questions on my Google+ or FB page.

I've been through this and will be glad to offer advice.


 - Dr. Gennady Kolodenker