A 50-year-old man who is a chronic smoker comes with pain and swelling in his ankle region. He denies any recent trauma or overuse. The pain is consistent and has been increasing gradually over two weeks. Physical examination reveals an area of warmth, redness, and tenderness over the medial malleolus. What should be considered, and what are the next steps?
Given this patient's chronic smoking history and the presence of pain, redness, warmth, and tenderness over the medial malleolus without a history of trauma, one consideration should be osteomyelitis, a bone infection that could occur from hematogenous spread, especially in patients with risk factors like smoking. It's also crucial to rule out gout or cellulitis. The next steps would include lab tests like CBC, ESR, CRP, and possibly blood cultures, as well as imaging, initially with an X-ray and potentially an MRI for better sensitivity. If osteomyelitis is suspected, consultation with infectious disease and orthopedic surgery for possible biopsy would be appropriate.