PODIATRY TREATMENT OF A PATIENT

      Justin Case is a 34 year Old construction worker who comes to you with an itchy rash on his foot which you diagnose as tinea pedis and possible onychomycosis. The full patient record can be found with in this document below .   to produce a response to the case study of no more than 1670 words thinking about the following.And should be in an essay format. More marks are given on the treatment more words on that section How and why may Justin have acquired this problem? How should a podiatrist best manage (treat) this problem, safely and effectively? Also as a patient with an active infection what measures should the practitioner take in the clinic to prevent the spread of this infection to others? Finally, what would be good advice for Mr Case to help him treat the infection and prevent the problem from reoccurring?       PODIATRY TREATMENT RECORD Patients Details Surname (Mr/Mrs/Miss) Case Forenames Justin Full Address 53 Coronation Street, Albert Square Achingfoot , Hampshire Postcode: SO77 1PF Telephone Home 264867 Work Ext Change of Address Next of Kin Name Mr s Iona Case (wife) Phone 07739 000000 Family Doctor Name Dr Prodd Change Dr Address Payne Surgery, Passmore Street, Achingfoot Personal Details Date of Birth 6 5 77 Married Single Widowed Divorced Height Ft 6 0 Ins Weight 14 St lbs cms Kg Occupation Builder Previous Occupation If school child, name of school Transport Requirements Ambulance Hospital Car Public Transport Voluntary Car Own Transport Domiciliary Footwear Appraisal Shoe Size 11 Type worn Work boot with steel toe cap. Rubber soles. PVC upper construction with laces. Soles well worn and thin. Splitting across sole of shoe (forefoot). Previous Podiatry Has the patient had podiatry treatment in the last year? YES NO Date of last treatment If YES, Name of podiatrist/clinic attended Give reason for last treatment Primary Assessment & Examination A Chief Concern Write in patients own words “I’ve got this itchy foot which is sore and driving me mad ” Medical History Illness Operations Injuries Allergies Familial Social Meningitis 1984 Appendectomy 1989. Fractured 3rd metatarsal (R). 1991 football injury No known allergies Mother : Type II diabetes Smoker 10 a day 15 Units alcohol per week. Swims 3x week Drug Therapy No current medication. None in the last six months. Foot Pathology Nature Location Duration Onset Course Aggravated by Right Tinea Pedis Interdigital and plantar 3 months duration Not improving Sweating and footwear Left As right foot Patient name Justin Case Patient Number B Peripheral Vascular Colour Temperature Pulses Trophic Changes Veins Right Pink, as expected. Warm toes and feet DP /TP palpable (strong/regular). No varicosities. Capillary refill time 1 second. Left As right Foot Neurological Examination Reflexes Deep Reflexes Sensation: - Touch Heat Vibration Pain Patella R L Achilles R L Plantar Response R L Right All present (Patella, Achilles & normal plantar response) Present Light touch, heat, cold, vibration, all appreciated. 10G monofilament 10/10 Left As right foot 10G monofilament detected 10/10 Skin Survey Detail: - Lesions Pigmentation Nail conditions Hair & Skin Glands Right 1st Nail dystrophic, friable and discoloured distally under the nail plate. Hyperhidrotic Feet Mole (naevus), apex of third toe. 3mm diameter. Uniform colour and borders. Orthopaedic Assessment General overview Range of motion (specify rigidity) Stance Gait Good range of motion (first/mid - tarsal/sub - talar/ankle) Tibial varum – bilateral No history of pain/discomfort Stance: Angle and base of gait as expected Early heel lift noted. Clinical Tests State Type: Gait Analysis Biomechanical Evaluation X - ray Pathology Lab Other: - Impression / Diagnosis 1.Tinea Pedis with suspected nail involvement