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Post by Gillian on Jan 13, 2010 19:22:29 GMT
hi there
I have a 78 diabetic patient who's left great toe has a O/x nail which is thickened down past the eponychium right to the matrix. Can anyone advise how best to treat this? I am concerned that he will get an infection under the prox nail fold and since he is diabetic with PVD,previous leg ulcers and absent pulses he is a high risk patient. I know he should be referred to specialist year oldpodiatry team at the local hospital but he just wont go. Any advise
cheers
gillian
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seekerofwisdom
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Post by seekerofwisdom on Jan 13, 2010 22:03:35 GMT
Can you tell us if you are a pod or an FHP and then someone will be able to give you the appropriate advice ?
SOW
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Post by seekerofwisdom on Jan 14, 2010 9:23:35 GMT
I'm not sure what the actual problem is here? Is it the "loose eponychium" (what is that BTW?) or the o/x nail? Most o/x nails are o/x right down to the matrix so why can't the bulky nail just be reduced. If you don't feel competant to do that that for goodness sake refer on to someone who can !
A N Other
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Post by seekerofwisdom on Jan 14, 2010 19:33:09 GMT
I dont have a clue what you mean by loose eponychium therefore I surmise that you must be an FHP? There is no reason that he should get an infection under the nail- what exactly is your scope of practise?
Sunseeker
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Post by Gillian on Jan 14, 2010 20:40:18 GMT
Hi there
Ok lets put it another way.
Whole nail is onychauxis including down to the matrix. the prox nail fold and cuticle are loose, not attached to the nail plate. My concern is that there is ample oppertunity for a bacterial infection to enter at this point and given that this is a high risk patient I am concerned. In 11 years in practice this is the only patient I have seen with this degree of loose cuticle. I just wondered if anyone had any advise to offer. Oh and by the way I'm not and FHP
i'm surprised that you don't know what the eponychium is? I got the impression you are a Pod. Surely you would know that terminology if you've avulsed a nail.
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Post by seekerofwisdom on Jan 15, 2010 8:09:43 GMT
Of course I know what an "eponychium" is, I didn't know what you meant by a "loose eponychium"? I've seen many cases where the nail plate loses contact with the cuticle, it's quite common. In these type of patients who lack sensitivity in their feet they can often come off due to trauma. I've had patients' come in with nails hanging off and the toe bloody/pussy and the patient totally unaware of the situation. It's also common for the nail to be onycauxic right down to the matrix. I am very surprised that you haven't seen this in 11 years of practice, or in your clinical training, which makes me suspect that you could be grandparented - am I correct? Anyway there isn't anything you can do to stop him getting an infection apart from adhering to a high standard of decontamination and cross infection procedures. These type of patients are an amputation waiting to happen, so be vigilant. If he won't go to the NHS pod, then that's his choice, but make sure you document his refusal.
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Post by Gillian on Jan 15, 2010 8:31:33 GMT
Hi there
Thanks for the reply. That was the answer I was looking for. I just wondered if there was anything else I could do to prevent risk of infection. I am presumming the thickness of the nail and pressure from shoes has forced the nail plate to separate from the cuticle. As per any diabetic patient I advise on good hygiene, checking for areas of pressure and good shoe fit. Even with reduction of the nail there is still pressure as it is thickened down to the matrix and this makes the cuticle and surrounding tissues feel firm to touch but what I am actually feeling is the thickened nail under the tissues. This patient in the ideal world would be best rid of this nail but his vascular status contraindicates this. Thanks for your advise anyway.
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Post by seekerofwisdom on Jan 17, 2010 7:55:40 GMT
This bit puzzles me. Are you sure it is the nail you are feeling and not an exostosis on the distal phalanx? Have you considered deflective padding?
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Post by seekerofwisdom on Jan 18, 2010 10:13:02 GMT
Gillian,
This is meant in a kind spirit.
No you are not a FHP but you are grandparented.
I'm not but I would not touch this guy with a barge pole, unless I had back up. I've done it for a lot of District nurses, but you do need this back up.
Do you know the extent of his PVD?
Shedding nails are not uncommon, especially when thickened.
However what you do not know is the reason for it shedding.
Whether it is better to remove the nail then treat the exposed nail bed is a matter of judgment, but I would advise not your judgment.
Find a way of convincing him to seek other support.
How will you feel if in 6 months time his toe is gangrenous and dropping off.
We all have our limitations.
A well wisher.
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Post by davidsmith on Jan 30, 2010 14:30:43 GMT
I dont have a clue what you mean by loose eponychium therefore I surmise that you must be an FHP? There is no reason that he should get an infection under the nail- what exactly is your scope of practise? Sunseeker From the Thesaurus some of the words related to ‘Loose’ = slack, unfastened, detached, untethered, free, baggy, unchained, unsecure, slack, roomy, moveable, lax, relaxed, droopy, sagging, limp. So if you’re not being obstructive and unhelpful then I would think that it would be quite reasonable for Gillian to assume that in the term ‘Loose eponychium’ that it would be Eponychium that you didn’t understand, since loose describes exactly the state of the eponychium for her patient. Would you prefer the term lysis, for instance the medical dictionary defines epidermolysis epidermolysis /epi•der•mol•y•sis/ (-der-mol´ĭ-sis) a loosened state of the epidermis with formation of blebs and bullae, occurring either spontaneously or at the site of trauma.epidermolyt´ic If you were being unhelpful, awkward, obstreperous etc then of course I can understand your objection to someone you thought to be a subordinate using a simple yet specifically unambiguous and descriptive term that however does not contain sufficient syllables to qualify for the ‘sagacious responses by the qualified imbecile club otherwise known as the SARQUI response. Anonymous sarqui response to boot (as well), which of course is =>Sagacious Responses by the Qualified Invertebrate Imbecile SARQUII, you’re not French are you? BTW what term would you prefer as you did not offer a more suitable alternative. Oh no sorry you didn’t know what loose meant so how could you offer an alternative, silly me eh? LoL Dave PS Gillian, can't you reduce the proximal nail edge with a blacks file, usually the nail under the LOOSE eponychium is quite soft. This is quite a regular finding for me and reducing the nail here increases comfort for the patient and reduces the risk of pressure trauma and often there is a tender swelling around this area, which is resolved when the nail is reduced and many times it also releases pus from a pyogenic infection or fluid build up from the fungal infection. I often irrigate under there to clean the cavity thoroughly. If there was infection packing with inadine is good or finishing with a topical antifungual. Dave
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Post by seekerofwisdom on Jan 30, 2010 19:04:47 GMT
Dave You are obviously in tune with the grandpareted lingo- well done for interpretting what Gillian was attempting to say.
As for the rest of your post, a little unnecessary dont you think? Nothing better to do on a beautiful Saturday then?
Sunseeker
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