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Am Fam Physician. 2021;103(4):201

Author disclosure: No relevant financial affiliations.

To the Editor: An 85-year-old patient with hypertension, coronary artery disease, peripheral vascular disease, vascular dementia, diabetes mellitus, and chronic kidney disease was residing in an assisted living facility due to dementia and care dependency. The patient's family was fully involved in care before but could not visit once the coronavirus disease 2019 pandemic began. Facility staff noted the new onset of reddish discoloration of the left great toe with drainage and a cold foot and notified the patient's primary care physician. Triage staff arranged a same-day urgent virtual visit, during which the physician noticed erythema from the base of the toe to the midfoot but was unable to visualize drainage because of its location on the plantar aspect in a patient with limited mobility. The diagnosis was foot cellulitis with possible deeper infection, and oral doxycycline was initiated with an in-person follow-up scheduled for the next day. At the in-person appointment, the patient was diagnosed with a toe ulcer and eschar in the plantar aspect with brownish serous drainage complicated by cellulitis of the foot and was referred to the emergency department.

The patient was evaluated by vascular surgery and was diagnosed with a plantar ulcer with necrotizing soft tissue infection of the foot and subcutaneous gas on imaging. The patient had a below-knee guillotine amputation and was discharged to a subacute rehabilitation facility after a prolonged hospitalization complicated by delirium, dysphagia, and aspiration pneumonia.

Virtual care has increased immensely during the pandemic in all specialties, including geriatrics.1 Virtual visits for skin conditions that require special positioning can be challenging in patients with dementia. In this case, the virtual visit critically delayed a time-sensitive diagnosis, despite appropriate triaging and subsequent care. This case illustrates the limitations of virtual care for patients with cognitive and functional impairment in alternative living environments. Clinicians should understand the limitations of virtual care in older adults and expedite in-person care as appropriate. We also recommend that practices identify a list of inappropriate virtual visit scenarios to guide the triaging staff.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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