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March 2016: Extremities

A 23-year-old male roustabout reports to the clinic complaining of itching and swelling of his foot for two days. About three weeks prior he noticed that his toes were “itching” after working in his crawfish fields. He used an OTC foot powder, which provided temporary relief. However he did not bring his foot powder with him this hitch. He has experienced this once before in high school while playing football.

He denies fever, chills, body aches, contact with solvents/soaps/shampoos, and pain with ambulation.

  • Past Medical History: obesity
  • Past Surgical History: orchiepexy
  • Current Medications: none
  • Allergies: Penicillin
  • Immunization Status: Up to date including annual flu vaccine
  • Social History: Social drinker, dips one can/day,
  • Family History: Mother- diabetes, hypertension; Father- diabetes, hypertension; Sister- hypertension, depression

Vitals

  • Temp 98.7
  • Pulse 94
  • Respiration 18
  • BP 139/86
  • POx 99% on Room Air
  • Weigh: 310 lb, BMI 41
  • Height: 6’1”

Focused Physical Exam

  • General: A&Ox3, obese male, sitting on the exam table, appears comfortable
  • Cardio: tachycardic, regular rhythm, no murmurs appreciated
  • Lung: tachypneic, clear to auscultation bilaterally
  • Abdomen: protuberant, soft, non-tender, non-distended, normal bowel sounds
  • Extremities: no clubbing, cyanosis or edema, good peripheral pulses, muscle strength 5/5 bilaterally, 1+pedal pulses bilaterally,
  • Skin: multiple erythematous vesicles noted to the web spaces between digits 2-4 of the left foot and 2-5 on the right foot; erythematous bullae noted on dorsal aspect of 2nd right digit; mild-moderate swelling on the dorsal surface right foot
  • Nail: Great toe thick and yellow bilaterally

1 Joyce 031013 0100P3120010

Lab Work

  • AccuCheck: non-fasting 150 mg/dl

How would you approach this patient?

Differential Diagnosis

  • Tinea Pedis
  • Cellulitis/abscess
  • Contact dermatitis
  • Necrotizing fasciitis

Diagnosis: Tinea Pedis

Treatment:

  • Keep feet clean and dry
  • Topical antifungal treatment
  • Oral antibiotics
  • Change socks multiple times daily
  • Foot coverings must be worn in common areas including shower
  • Monitor treatment daily

Discussion:

Tinea Pedis is a very common infection found in warm moist environments caused by a genus of fungi called Trichophyton. The fungi are found in common areas such as the floor surfaces of showers and locker rooms.

In most cases, this is easy to resolve with OTC topical antifungal agents. Duration of therapy can last 1-4 weeks with topical therapy and good hygiene. Certain oral antifungals may require up to 8 weeks of treatment. Secondary bacterial infections can complicate the case requiring oral antibiotic treatment.

For this patient we chose to use a topical antifungal cream due to ease of use and potential for quicker resolution. This patient exhibited redness and swelling indicating a secondary bacterial infection requiring oral antibiotics. The additional finding of nail fungus (onychomycosis) will require the patient to seek additional care from his primary care provider. Fungal nail infections do require oral antifungal treatment for up to 12 weeks and monitoring of kidney and liver function. The bacterial infection seemed to be progressively working despite oral antibiotic therapy and therefore required CASEVAC for further evaluation.

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