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Differentails and lab tests

Discussion in 'Diabetic Foot & Wound Management' started by punch_biopsy, Oct 3, 2011.

  1. punch_biopsy

    punch_biopsy Welcome New Poster


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    A 38 y/o patient comes into your clinic
    complaining of a painful “infection” between his toes.
    He noticed the infection about two months after joining a new gym four months ago (he was recently diagnosed with glomerulonephritis and has decided to improve his health via changes in diet and exercise). At first it was a bit red and itchy, and someone at the gym told him it was probably Athlete’s foot, so the patient tried using some OTC medicated foot powder, applied in his socks, daily. He has not noticed any improvement and has more recently noticed whitish discoloration and cracks in the skin. The area
    shown below is the worst involved, and has become swollen and painful in the last
    couple of weeks so he has come to see you.
    he states that typically he is generally in good health but over the past week or so
    he has not felt very good with flu-like symptoms.

    MEDS: Crestor 10mg qd, Altace 2.5mg qd, Prednisone 10mg qd.
    ALLERGIES: Septra
    MED HX: Saw GP 7 months ago for annual checkup: (+) Glomerulonephritis. Slightly
    overweight (↑BMI).
    SURGICAL HX: R/ Ankle fracture, playing football in highschool.
    PSYCH/SOC. HX: Married, social drinker. Non-smoker.
    FAMILY HX: Parents have hypercholesterolemia, hypertension. Father had MI around
    age 55.
    ROS: Unremarkable with exception of flu symptoms. Generalized bloating due to
    medications.

    PHYSICAL EXAM
    VITALS: Temp – 38.9ºC.
    VASC: DP/PT/AT pulses +2 b/l. CFT < 3sec for all digits b/l. Left forefoot feels warmer in
    temperature to the contralateral foot.
    NEURO: Protective and vibratory sensation intact b/l.
    DERM: Normal skin turgor and texture b/l lower extremity. All webspaces are
    erythematous with varying degrees of maceration. Slight odour noted. 2nd webspace left
    is notably macerated with break in skin integrity, erythema extends onto dorsum of
    forefoot. No purulence noted. Cicatrix on both medial & lateral malleolus, right.
    MSK: No abnormal findings.
    BIOMECH: Decreased ankle dorsiflexion b/l. All other ROM are WNL.

    -----------------------------

    This is a case study we are doing, and we just wanted to see what other views are out there. We have our own thoughts and will post them on here after we hear some of your own. Please feel free to discuss.

    Lab tests to do and differentials.
     
  2. blinda

    blinda MVP

  3. Joe Bean

    Joe Bean Active Member

    Can you dismiss psoriasis?

    Caught me out once, looked like raging Tinea.
     
  4. blinda

    blinda MVP

    OK, punch,

    Forgive my pithy post, I should have said :welcome: to the Arena.

    Assuming "we" are students, why don`t you first tell us your collective thoughts and the clinical reasoning behind those thoughts? That would be a good start.

    Cheers,
    Bel
     
  5. Joe Bean

    Joe Bean Active Member

    Nice reply Bel.

    Being an older practitioner I was taught that 'test' were to confirm one's diagnosis not to aid the diagnosis!

    Or to get time as one had failed to get a diagnosis.

    This post reminds me of ER (great show) loads of tests very US?

    Tell me Bel is Dermo still mainly an 'obsevational' discipline?

    Joe (ex pat)
     
  6. blinda

    blinda MVP


    Thank you, Joe. Is it Pat on weekends only?

    Don`t be fooled by my avatar, I`m no spring chicken myself.

    It rather depends on what your definition of `test` is. If you are refering to skin or nail samples taken for microscopy and culture then often, but not always, the initial (observational) clinical diagnosis is confirmed by the lab results. Personally, I think such tests are a waste of NHS money and time as most pods can easily spot bacterial and (smell) tinea, thus recommend effective and appropriate OTC meds, yet some GPs insist on a lab report before they are willing to even comtemplate prescribing anti-fungals.

    However, if you are presented with a lesion, or rash, that you are unsure of then either differential or definative diagnosis can only be found by further investigation. As with all things podiatry-wise, we should ask ourselves how the results of any investigation is going to alter or support our treatment plan for any particular pt. If they don`t effect it, then why do it?

    In the main, I would say observation and medical history are the key factors, obviously. That said, smell and palpation are pretty important. Draw the line at taste though.
     
  7. RobinP

    RobinP Well-Known Member

    I hope that was the patient holding those toes apart because I, for one, would not be going near anything like that without gloves. But then, I am an orthotist and I get a bit sqeamish ;)
     
  8. punch_biopsy

    punch_biopsy Welcome New Poster

    Hey, thanks for all the replies!

    Here are our Dx and Dxx's:

    Fungal infection with secondary Bacteria infection:
    Tinea Pedis Interdigitalis (Dermatophytosis Complex) which opened the skin.
    Staph. Aureus infected the site and lead to a gram negative shift to a pseudomonas infection. (The slight odour is showing evidence of the shift to pseudomonas, as well as the beginnings of systemic infection from the flu-like symptoms).

    Dxx

    Cellulitis: Hyperhydrosis causing maceration in the webspaces of the toes. Which has opened up the integrity of the dermal and subcutaneous layers of the skin, leading to inflammation and infection in the form of Cellulitis.

    Dxxx

    Intertrigo: Increased rubbing between his toes due to improper footwear caused rubbing of the webspaces when he started excercising. This caused compromised the skin integrity, and allowed a bacterial or viral or fungal infection. ( I am confused about this process though, should we state which of those three organisms we think it is? Or is that good enough for the differential? Also, is Intertrigo just a descriptive term in this use, since the organism could vary so much?)

    Thanks for reading.

    Dxxxx
    Interdigital Psoriasis
     
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