Hi,
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An 80 yr patient presented, complaining of a 'sore big left toenail'. Assessment of the toe revealed no external signs of trauma, infection or involution. Nail sulci were completely clear of debris and nail edge was visible. Direct compression of the toenail ellicted pain, which immediately made me consider subungual exostosis. I couldn't acertain whether there was any additional blanching of his nailbed, as both L and R hallux nailplates were pale in colour.
I am keen to get possible differential diagnoses in light of his other symptoms and med Hx: temperature of his feet was hot distally, but cooler proximally, which was unusual. Skin slightly anhydrotic. Erythema extended unilaterally into the distal 1/3 of the left limb. The 'erythema' took on the appearance of tiny pinpoint capillaries sub-epidermally, as opposed to irritation on the surface of the skin. The erythema was not symptomatic. The patient is also living with asbestosis (on oxygen permanently), emphysema and leukaemia. Now he has a sore toe to add to his problems!
I have read that x-rays may not be the best way of diagnosing a sub-ung exostosis, particularly if it has a cartilagenous cap. What is the best way to conclusively diagnose this condition? Could it be something more sinister in light of his medical history?
Interested in your advice and suggestions!
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