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