Assignment Task

Case 1

Presenting Complaint:

A patient presents to you complaining of a painful right big toe. She has experienced pain on and off for quite some time, but now the toe at the bottom of the nail is erythematous, warm and painful with purulent exudate visible. She is struggling to wear shoes because of the pain.

Background:

The patient is a 32 year old female (height 165cm, weight 72 kg) who lives with her husband and two children (aged 4 and 6). She works in hospitality and is on her feet a lot. She swims 1-2 times per week but does no other exercise as she is physically active as part of her job. Upon assessment you note that the proximal nail fold of her right Hallux is erythematous, warm to touch, painful upon palpation (VAS pain score of 8/10 when weight bearing) and exuding purulent exudate. The patient has the area covered with a band-aid and is wearing thongs to stop her shoes pressing on the area. Both Dorsalis Pedis and Posterior Tibial pulses are palpable bilaterally and further assessment with Doppler reveals strong triphasic sounds in both feet. Patient is fully sensate scoring 3/3 with 10 g Monofilament bilaterally.

Medical History

• Migraine

Medications

• Yasmin oral contraceptive pill x1 daily by mouth
• Naratriptan for acute migraine, 2.5 mg orally prn

Allergies and Drug Sensitivities

Penicillins – breathing difficulty and skin eruptions following single dose of Augmentin Duo Forte 4 years ago

Diagnosis and Non-pharmacological Management Acute on chronic paronychia at the proximal nail fold of the right Hallux, typically caused by Staphylococcus bacteria. You drain the area of purulent exudate as much as possible given her pain. You apply the antimicrobial dressing Sorbact with a secondary Mepilex Border dressing. The patient should keep this dressing intact and dry, changing to a clean dressing every 3 days. Patient is issued with a post-operative shoe (Darco shoe) to keep pressure off the infected area and is advised to avoid wearing closed-in shoes until the issue is resolved.

Pharmacological Management

What will you prescribe for the infection and for pain management. 

Case 2

Presenting Complaint:

A patient presents to you complaining of a painful area at the back of their heel. They have had a ‘bump’ there for quite a few years, but it has never really bothered them. Over the past 3 months the pain in the area has increased and taking regular Paracetamol (500mg tablets, x2 orally every 4 hours) in combination with Ibuprofen (200 mg tablets, x2 orally every 8 hours) as recommended by the GP has not helped with pain. The patient finds wearing shoes uncomfortable now and is restricted in terms of walking and exercise due to pain.

Background:

The patient is a 40 year old man (height 183 cm, weight 125kg) who lives alone. He is employed full time as an architect. Before the pain in his heel worsened, he walked his dog every night for approximately 1 hour and played basketball with friends once a week. His walking is now limited to about 20 minutes every second night, and he has not played basketball for a month.

Upon assessment you note a Haglund’s deformity on the left posterior heel that is oedematous, mildly red and painful under direct pressure and any form of palpation. Patient reports pain is a 8/10 when wearing shoes and walking and when palpated (using 10 point VAS scale).

All pulses are palpable bilaterally with Doppler producing biphasic sounds at both he Dorsalis Pedis and the Posterior Tibial arteries. Patient scored 3/3 bilaterally when assessed using a 10g monofilament. Biomechanical assessment reveals a pronated foot type (FPI +7), presence of early heel lift and mild abductory twist bilaterally.

Medical History:

• Hypercholesterolaemia
• Non-specific Low Back Pain

Medications:

• Lipitor 40 mg, x1 tablet orally once daily

Allergies and Drug Sensitivities:

• Lactose intolerance

Diagnosis and non-pharmacological treatment:

Retrocalcaneal bursitis secondary to Haglund’s Deformity. 10mm felt donut pad adhered with Fixomull hypoallergenic tape to offload the area. Patient advised to wear shoes with a heel cup that is soft and will accommodate the deformity/padding. Patient to keep dry and intact for 5 days. Once padding is removed, patient can apply ice to the area after activity to help manage pain. Patient provided with 3mm heel lifts to reduce tension at the Tendo Achilles insertion. Long term patient will require stretching program to improve ankle dorsiflexion and further reduce tension at the Tendo Achilles insertion at the posterior heel.

Pharmacological Management:

Outline the medicines you will administer (including dose and amount) for this injection.

Case 3

Presenting Complaint:

The patient presents to you concerned about the appearance of his left big toenail. The whole nail is affected and is thick, opaque and yellow looking. The patient is concerned about this spreading to his other nails and although he has no pain, he does not like the way it looks and has stopped wearing open toe shoes or walking barefoot.

Background:

• 74 years old, married for 30 years and lives with his wife
• Retired for 8 years and likes to read and listen to music
• Non-smoker
• Drinks alcohol with meals most days (1-2 standard drinks)
• BMI 29.7 kg/m2 (92kg, 178 cm)
• Exercises regularly walking 30-60 minutes per day with his wife

Medical History:

• Coronary artery bypass surgery 6 years ago with a further stent inserted 2 years ago
• Angina
• Hypertension, well managed, last BP 140/78 mmHg
• Hyperlipidaemia, total cholesterol < 4mmol>
• Osteoarthritis affecting his lower back

Medications:

• Atorvastatin 40 mg daily
• Aspirin 100 mg daily
• Clopidogrel 75 mg daily
• Irbesartan 300 mg daily
• Diltiazem SR 240 mg daily
• Paracetamol SR 6665mg, 2 tablets 3 times a day
• Meloxicam 15 mg daily as needed for back pain

Allergies and Drug Sensitivities:

Penicillins – breathing difficulty and skin eruptions following single dose of Augmentin Duo Forte 4 years ago

Diagnosis and Non-pharmacological Management:

Topical dystrophic onychomycosis caused by infection from Trichophyton species including Trichophyton rubrum and Trichophyton mentagrophytes affecting the whole nail plate

Non-pharmacological Management:

• Disinfection of hosiery
• Disinfection of footwear
• Avoid walking barefoot

Pharmacological Management

What will you prescribe for the management of this condition.

Case 4

Presenting Complaint:

This patient presents to you complaining of a rash on her foot and ankle. The patient reports that they recently moved house and have been tidying up the garden in her new place. She spent most of Saturday in the garden and noticed the rash appearing that night. It has now spread and is itchy and uncomfortable.

Background:

• 68 years old
• Lives with her husband, both retired
• Has five adult children and 4 grandchildren
• Is an avid gardener and is very active in her local community as a volunteer
• Non-drinker and non-smoker

Medical History:

• Asthma – diagnosed as a child, has asthma plan in place
• Allergic rhinitis
• Nasal polyps
• Mild osteoarthritis affecting both hands especially her thumbs

Medications:

• Seretide (fluticasone/salmeterol) 250/25 MDI 2 puffs twice a day
• Ventolin (salbutamol) 100 mcg MDI as needed
• Ostelin 25 mcg (1000 IU) 1 tablet twice a day
• Caltrate 600 mg 1 tablet once a day
• Nasonex 50 mcg 1 spray to each nostril daily
• Uses various over the counter antihistamines generally during spring
• Panadol osteo 665 mg as needed for pain in hands

Allergies and Drug Sensitivities:

NSAIDS, patient is hypersensitive to all NSAIDS. Taking these medications can results in onset of severe asthma.

Diagnosis and Non-pharmacological Management:

Allergic contact dermatitis.

Non-pharmacological Management:

• Avoid scratching the affected area
• Avoid the irritant if known
• Keep affected areas clean
• Apply cool compress or use cool foot baths
• Apply a moisturiser
• Do not break vesicles if they appear

Pharmacological Management What will you prescribe for the management of this condition.