Sever Disease is calcaneal apophysitis, an overuse irritation of the cartilaginous spot where the Achilles tendon attaches to the calcaneus (heel bone). It is seen most often in active children 7-14 years old. Diagnosis is as simple as reproducing the pain by squeezing the heel. As long as the child can walk/play without limp, a padded heel cup is sufficient treatment. Labs and imaging are not required. However, if the pain causes the patient alter his/her gait, then s/he needs to sit out of the offending activity. IF there is swelling or mechanical disruption (catching, locking), then it's NOT Sever Disease, and you should look for another cause.
TL;DR: There is no need to SEVER the foot in Sever Disease; supportive care generally suffices.
Pro Tip: Sever Disease is to the ankle what Osgood-Schlatter Disease is to the quadriceps tendon and tibial tuberosity. An analogous upper extremity injury is proximal humeral epiphysiolysis aka Little League Shoulder. For an excellent breakdown, see Little League Shoulder.
Image: Weerakkody Y, Jarvis M, Foster T, et al. Calcaneal apophysitis. Reference article, Radiopaedia.org (Accessed on 18 Mar 2023) https://doi.org/10.53347/rID-10681
When I am asked about my future plans, my response is rightfully met with confusion. I am entering the workforce as an academic internal medicine physician devoting my practice entirely to the outpatient setting. Yet, two-thirds of my residency training has been managing patients within the walls of a hospital. That disconnect raises interesting questions about my career choice, and, naturally, makes me an anomaly among my peers.
"When I am asked about my future plans, my response is rightfully met with confusion. I am entering the workforce as an academic internal medicine physician devoting my practice entirely to the outpatient setting. Yet, two-thirds of my residency training has been managing patients within the walls of a hospital."
Internal medicine resident Ryan Yarnall, MD, shares the importance of #ambulatorymedicine. Published on in-House, the online peer-reviewed publication for residents and fellows.
The primary care (aka general practice) rotation is essentially two weeks in which to become comfortable dealing with the cases that will make up 95% of our workload as vets. This includes vaccinations, ear infections, itchy skin, sore eyes, dental disease, wounds, lameness, and so on. The rotation also focusses on developing our client communication skills through consultations with pet owners.
For the majority of the days we pretended to be real veterinarians. We assigned ourselves to cases which we followed from beginning to end. When our patients arrived, we greeted the owners, collected a detailed history and performed a thorough physical examination of the patient. We reported our findings to the responsible vet and together we formulated a diagnostic and treatment plan. The vet then conveyed this to the client. If any procedures needed to be performed (such as blood collection, ultrasound scan or wound clean), we were allowed to assist. The patient’s hospital report was also our responsibility.
To assess our client communication skills, we had to record our consultations using hidden cameras and microphones (with the client’s permission, of course). Believe me when I say there is nothing more uncomfortable than watching yourself pretending to be a vet. Sooo cringe-worthy! I am awkward at the best of times, but when the camera is rolling, everything seems to go pear shaped. Like when I put my stethoscope in my ears backwards, took it out, looked at it for a moment, and then put it back in the same way. Face palm. I wasn’t the only one with embarrassing footage though. One of my classmates tripped over a dog, another couldn’t hold onto her cat, and someone else had a stubborn dog that planted his butt firmly on the ground and refused to let anyone take his temperature. Between us, we could’ve made a hilarious blooper reel!
In between consultations, the primary care vets organised some informal tutorials on vaccinations, ear and eye medications, and eye examinations. These were really, really helpful.
One day of the rotation was spent “on procedures”. I scrubbed into a digit amputation and lump removal in a dog. I also watched a cystotomy (surgery involving an incision into the urinary bladder) in a dog with a bladder stone. I had another day in the dental clinic where I got to brush up (pun intended) on my scaling and polishing, and watch several extractions. Another day I was stationed at an external vet practice to observe the vets consulting and pick up some tips and tricks from the experts. I also had a day in the exotic pet clinic. I saw some really interesting cases there, including a rabbit respiratory emergency, a python exhibiting neurological signs, and a ridge-tailed monitor that fell from a height and fractured its spine resulting in paralysis of its hind legs.
The final day of the rotation was examination day. We started with an online exam which covered random topics that did not at all reflect what we’d been learning over the fortnight. Straight after that I had a history taking exam. I had to pretend to be a vet and collect a history from the ‘client’ (an actor) while an examiner sat in the corner of the room with a clipboard. I freaked out and forgot everything I knew. There’s a reason I didn’t pursue an acting career! I walked straight out of that exam and into the next. The clinical skills exam should have been easy, but my nerves got the better of me and my hands shook so much that I managed to shatter a glass tube! The final assault was playing my consultation recording in front of a small audience while the examiner critiqued my words, body language and expressions.
At the end of the day, we each had an individual feedback session with one of the primary care vets. When it was my turn, I was feeling a bit like a lamb for slaughter, but my skin was thick and I was ready for the next wave of criticism. Lay it on me! I was completely taken aback when I was instead flooded with praise and encouraging words.
I really appreciated the kindness, patience and support from the primary care staff. It makes all the difference at this point in the year (and degree).
#thankful for #our #family #physician Dr. Aiku, #my #primarycare #doctor #holding #her #copy of my #number #one #bestseller #available on #amazon. #miraclesdohappen #we are #living #proof. #female #author #authorsofinstagram
When the President's Commission on Combating Drug Addiction and the Opioid Crisis
declares “addiction [a] chronic relapsing disease of the brain”1 and calls for expanded
access to care, within those statements is recognition of the influx of patients with
addiction into general medicine settings for chronic disease management. The initial
conversations that can shape a patient's understanding of addiction will occur more
and more within primary care offices or at the bedside in the general medicine wards.
"What do you think caused your addiction? How does it change your body or mind? These questions can start the conversation about the patient's explanatory model of addiction. Eliciting a patient's explanatory model can go hand in hand with understanding a patient's readiness to change and personal goals."
The biopsychosocial model of disease encourages us to share knowledge and decision-making with our patients, beginning with their understanding of their disease.
Helen E. Jack, et alia, "Asking How Our Patients Understand Addiction," American Journal of Medicine, Volume 132, Issue 3 (March 2019): 269–271.
The CAGE questionnaire is good for assessing physical dependence on alcohol:
1. Have you ever felt you should CUT back on your drinking?
2. Have people ANNOYED you by criticizing your drinking?
3. Have you ever felt GUILTY about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (EYE-OPENER)?
A score of 1 is concerning and 2 is definitely postive.
