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Post by stella1964 on Jul 11, 2009 21:57:06 GMT
I have a diabetic lady who appears to have possibly traumatised her 2nd apical digit since my last routine visit. When I saw her last I found a dry haematoma area apically and what looked like a sub-ungual haematoma below the nail (old). There was no signs of infection or discomfort for her. I thinned the nail and pared the dry apical area to relieve from any pressure. Have I done enough?
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seekerofwisdom
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Post by seekerofwisdom on Jul 12, 2009 4:45:26 GMT
Stella,
‘Have I done enough’?
Interesting question, possibly more than enough.
This is not meant to be impolite but I feel the need to correct some if not all of your post.
a) What is a ‘diabetic lady’. For this description to have any relevance you need to supply more information like age, general health, type of diabetes, method of control and stability of control. Plus and always plus any complications of the diabetes.
b) ‘Traumatised her second apical digit’. What is an apical digit? Did you mean she had a bruise on the apex of her second toe?
c) ‘What looks like a sub-ungual haematoma below the nail (old). Where else would you find a sub-ungual haematoma than below the nail. Was it older than your last routine visit?
d) You can have the cardinal signs of infection but discomfort is a sensation not a sign.
Ok being a bit picky perhaps?
So why did you thin the nail, and why remove the covering of a ‘dry’ haematoma, surly if it was dry there would be no pressure?
So how did your history taking go? Did you ask the patient how the toe had come to be bruised? If not by a single traumatic incident what could the other possible causes be?
And finally what constitutes a ‘routine visit’?
Shy.
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Post by dewdrop on Jul 12, 2009 7:28:23 GMT
Hello Stella, It is difficult to answer your question without more information, as Shy says. It is a pity we do not have a picture of the lesion.
You do not say how old your patient is, whether they are a Type 1 or 2 Diabetic and how long it was since your last visit.
So here are some questions that you might like to consider.
Are you sure it is a subungual haematoma? The differential diagnosis of this includes benign and malignant tumours, longitudinal pigmented band (melanonychia straita), onychomycosis and subungual exostosis. Was the lesion there last time you visited? Can the patient recall a history of trauma? - if not, it may be necessary to rule out a pigmented lesion.
'No pain' does not necessarily equate to 'no problem' in a diabetic because of the possiblity of impaired sensation. What is the neurological status of that foot, specifically that toe? What did you record at the last diabetic assessment and had it changed this time?
If the lesion is due to trauma, how did this occur? Did the patient trip or fall? Does the footwear need to be addressed? Does the patient wear suitable footwear or are the infamous "sloppy slippers" in evidence?
The patient should be encouraged to wear appropriate-fitting footwear to prevent trauma between the footwear and the toe.
Could the patient have tripped or fallen due to a hypoglycaemic episode? Does the GP need to be informed and the drug regime modified?
I am not sure why you chose to remove this lesion. You say it was to remove pressure but not from where. If there is pressure than maybe it needs to be deflected, perhaps by padding, chairside appliance or orthotic?
That's just my two cents. I am sure the diabetic expert on the forum will be able to give you a fuller answer.
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seekerofwisdom
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Post by seekerofwisdom on Jul 12, 2009 8:16:00 GMT
hello stella The previous 2 answers have been very explanatory , however, assuming you are a podiatrist and not a foot health practitioner, you know your patient well if she regularly has treatment from you and would understand the implications of diabetes. When you say haematoma, do you mean a bruise or do you mean extravasation of blood into the apical tissues? If it was the latter, then this is usually a sign of a high pressure area which should be offloaded . There could be an underlying breakdown of tissue here, so may be that is why you debrided a little? I have often found ulcers like this, and it is better to treat early before they become complicated. The lack of pain is of course possibly down to diabetic neuropathy, so often the patient is unaware of the problem. If you have any doubts regarding care of diabetics it is always better to refer on to someone with more experience.
VP(virgin poster)
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Post by Admin on Jul 12, 2009 18:30:29 GMT
Hey stella and hey VP. Welcome!
Good question, Great answers!
As my rt hon colleagues observe the answer to your question, have I done enough, is impossible without more info. A picture is better yet, if you don't know how to upload one email it to me and I'll do it for you.
As VP says, with a dry ub ung Haematoma you need to know if it was traumatic or if there was pressure in need of release. Often one needs to debride to see whats going on underneath all the dried blood, there may well be an open lesion beneath.
Great DDX list too btw.
Regards Robert
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Post by stella1964 on Jul 12, 2009 19:54:12 GMT
Thank you for your responses. This lady is a type 1 diabetic, age 74 and has stable diabetes at this time. I have already liased with her GP regarding her monofilament tests and she is seen regularly by her diabetic nurse who is aware of the loss of sensation in her feet. We have all advised the client of foot care and footwear issues. The client had fallen she stated prior to my visit and this may have been what caused the trauma found on the apical area of her toe. There were no signs of inflammation at the time of my visit. The nail was o/x and I thinned this to reduce any further risk of pressure to the underlying tissue and apical area. I pared the dry haematoma down as I have seen this before in a diabetic (who also did not wear footwear and had slight dementia) which when pared I found an ulcer below - no obvious signs of this prior to paring. I see this client routinely for nail / foot care every 8 weeks at the clients request. If I am worried I will refer her back to her GP for further care with either the district nurses for dressings if required (not currently needed but I will monitor the area) and / or diabetic NHS chiropodists. I did discuss with my client on my initial visit re diabetic foot care etc and I issue a handout with basic foot / nail care info on it. I feel this is not any of the differential diagnosis you offered (Dewdrop) at this stage, I do feel this will either settle or it may develop an ulcer, possibly beneath the nail. If an ulcer is under the nail, what would your advice be please?
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seekerofwisdom
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Post by seekerofwisdom on Jul 12, 2009 20:54:45 GMT
Stella,
Congratulations what a different post your reply is.
But still some queries.
Thank you for your responses. This lady is a type 1 diabetic, age 74 and has stable diabetes at this time.
So she is insulin dependent from an early age? What is stable and what complications does she display?
I have already liased with her GP regarding her monofilament tests and she is seen regularly by her diabetic nurse who is aware of the loss of sensation in her feet
So she has neuropathy, how advanced is it?
We have all advised the client of foot care and footwear issues.
So can we assume you are a joined up member of this persons management team?
The client had fallen she stated prior to my visit and this may have been what caused the trauma found on the apical area of her toe. There were no signs of inflammation at the time of my visit.
Did you associate her fall with her diabetes or was it just part of the sh** of life?
The nail was o/x and I thinned this to reduce any further risk of pressure to the underlying tissue and apical area.
Hopefully if you are seeing this person on a regular basis her nail does nor extend to the apex of her toe?
One assumes the nail has always been OX so was the thinning this time 'significant'?
I pared the dry haematoma down as I have seen this before in a diabetic (who also did not wear footwear and had slight dementia) which when pared I found an ulcer below - no obvious signs of this prior to paring.
So a reasonable justification, especially as she is neuropathic. But did you consider why the sudden change in 8 weeks?
I see this client routinely for nail / foot care every 8 weeks at the clients request. If I am worried I will refer her back to her GP for further care with either the district nurses for dressings if required (not currently needed but I will monitor the area) and / or diabetic NHS chiropodists. I did discuss with my client on my initial visit re diabetic foot care etc and I issue a handout with basic foot / nail care info on it.
I feel this is not any of the differential diagnosis you offered (Dewdrop) at this stage, I do feel this will either settle or it may develop an ulcer, possibly beneath the nail.
Feelings should not enter into this you need to justify you reservations!.
If an ulcer is under the nail, what would your advice be please?
If you are operating outside of your competency pass it on,
Shy and brutal.
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Post by Admin on Jul 13, 2009 6:16:12 GMT
Admin says I have (very) slightly edited the above. Remember the rules guys. This is about the podiatry not the posters. Keep it relevant to the patient, not the people posting the questions. Robert says I think based on the information at hand that all sounds pretty reasonable. I'm not sure how relevant some of these assessment details are to the nitty gritty of real practice. I feel the diabetic neuropathy testing equipment and techniques are woefully inadequate and not especially relevant, but thats just a minority view I hold. Perhaps its time for that thread again. .
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Post by dewdrop on Jul 13, 2009 6:33:43 GMT
Hello Stella, I agree with Shy, if you are operating outside your field of competancy, pass it on. If you have not be trained in this area then do not embark on it until you have, as it could put you and your patient at risk. You by having your insurance compromised and the patient from the complications of diabetes. By "trainiing" I mean practical as well as theoretical. While this may be a good resource for gathering theoretical information it is no substitute for a day in a diabetic clinic debriding ulcers. If you want to learn more about diabetes then the Diabetic Foot Journal Conference and Exhibition this year is being held at The Ibis Hotel, Earls Court, London. This has a programme designed for both generalists and specialists and is well worth attending. You can obtain all the information you need about the programme and can book on-line at www.sbcommuicationsgroup.com/eventsThis year on the generalist track there is a presentation by Roger Gadsby, GP and Associate Clinical Professor (Warwick) on - "What goes wrong with the foot and what to do about it? - prevention of ulceration, re-ulceration and amputation. - what you can do to prevent foot problems and when to refer on?" As a matter of interest, was this modality not covered in your initial training programme?
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seekerofwisdom
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Post by seekerofwisdom on Jul 13, 2009 7:48:21 GMT
So admin, one is not allowed to establish the knowledge base of a poster?
Fair enough.
Robert.
I'm struggling to understand what you are saying in your contribution.
I think based on the information at hand that all sounds pretty reasonable.
The original information was woefully inadequate to either pass judgment or offer advice. The extra information I still feel does not warrant 'reasonable'.
I'm not sure how relevant some of these assessment details are to the nitty gritty of real practice.
Such as? First post said the apical haematoma was not painful? Well is she has significant neuropathy it would not be would it would it?
I feel the diabetic neuropathy testing equipment and techniques are woefully inadequate and not especially relevant, but thats just a minority view I hold.
As in 'not sensitive enough' so missing out on early stage changes or too sensitive so giving false positives? The EBM would of course disagree with you.
In either case should the OP ignore the information?
Shy.
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Post by dewdrop on Jul 13, 2009 8:22:58 GMT
Admin, If one cannot enquire about the knowledge base of the poster how can one give relevent information? Sounds perfectly reasonable to me?
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Post by Admin on Jul 13, 2009 13:44:06 GMT
ot
Indeed. But to state that a poster is incompetant is not. Its not a reasonable judgement to make based on the way they ask a question and its not going to encourage people to ask questions if their competancy is going to be called into question for asking them.
Give the information you feel is relevant. If the person asking the question finds the answer too complex (and I doubt they would in this case) its for them to request clarification.
Admin
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Post by robertisaacs on Jul 13, 2009 13:54:25 GMT
Hey Shy.
Opened a new thread for that rather interesting discussion.
See you on the flip side!
Robert
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seekerofwisdom
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Post by seekerofwisdom on Jul 13, 2009 15:06:16 GMT
With respect, stella has been asked several times if she is a pod - we have yet to have a straight answer- and yes it is totally relevant to know her qualifications when discussing the post.
VP
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Post by Admin on Jul 13, 2009 18:45:49 GMT
Possibly Stella does not owe you an answer. Shy requested that I respect her anonymity and of course I shall. Perhaps Stella too, is shy. But if you do not feel you can discuss this issue without knowing her background that is your perogative . Regards Admin
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