From the Guidelines
Diego's treatment plan should include a partial lateral nail avulsion under local anesthesia, followed by phenolization of the nail matrix to prevent regrowth, and oral antibiotics to address the infection, as recommended by the Infectious Diseases Society of America guidelines 1.
SOAP Note
A comprehensive SOAP note for Diego's ingrown toenail would include:
- Subjective: 25-year-old male presenting with infected ingrown toenail on the lateral side of left hallux (big toe), ongoing for one month. This is his third occurrence. Patient reports occasionally cutting nails too short, which may contribute to the condition. Pain is significant enough to warrant medical intervention.
- Objective: Examination reveals infection of the lateral aspect of left hallux nail with surrounding erythema, edema, and purulent discharge.
- Assessment: Onychocryptosis (ingrown toenail) with paronychia of left hallux, lateral nail fold.
- Plan:
- Partial lateral nail avulsion performed under local anesthesia (6 mL lidocaine required for adequate anesthesia).
- Phenolization of nail matrix performed to prevent regrowth.
- Wound dressed with antibiotic ointment and sterile dressing.
- Patient prescribed oral antibiotics for infection, such as amoxicillin-clavulanic acid or cefalexin, as recommended by the WHO Essential Medicines and Aware guidelines 1.
- Follow-up in one week for wound check.
- Patient educated on proper nail trimming techniques and footwear recommendations to prevent recurrence.
Procedure Note
For the procedure note: Patient underwent partial lateral nail avulsion of left hallux under local anesthesia. After digital block with 6 mL 1% lidocaine (additional anesthetic required due to initial inadequate numbing), the lateral portion of nail was separated from nail bed using nail elevator. The ingrown portion was cut longitudinally and removed. Phenol was applied to the lateral nail matrix for 3 minutes to prevent regrowth. The area was thoroughly irrigated with saline, dressed with antibiotic ointment and sterile dressing. Patient tolerated procedure well and was discharged with oral antibiotics, pain management instructions, and wound care guidance.
Antibiotic Selection
The selection of oral antibiotics should be based on the severity of the infection and the likely etiologic agent(s), as recommended by the Infectious Diseases Society of America guidelines 1. For mild to moderate infections, agents such as amoxicillin-clavulanic acid, cefalexin, or clindamycin may be suitable. For more severe infections, broader-spectrum antibiotics such as fluoroquinolones or linezolid may be necessary. The duration of antibiotic therapy should be based on the clinical response to treatment, with a typical course of 1-2 weeks for mild infections and 2-4 weeks for moderate to severe infections 1.
Wound Care
Proper wound care is essential for promoting healing and preventing further complications. This includes regular dressing changes, debridement of necrotic tissue, and off-loading of pressure to the affected area. The use of topical antimicrobial agents or dressings may also be beneficial in preventing infection and promoting wound healing 1.
Follow-up
Regular follow-up appointments are necessary to monitor the patient's progress and adjust the treatment plan as needed. This includes assessing the wound for signs of healing, monitoring for adverse reactions to antibiotics, and providing ongoing education on proper wound care and prevention of future infections.
From the FDA Drug Label
Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by neomycin sulfate tablets, USP or other antibacterial drugs in the future
- Soap Note:
- Subjective: Diego, a 25-year-old male, presents with an infected toenail on the left big toe, with a history of clipping his nails too short, which may contribute to the problem.
- Objective: Infection of the lateral aspect of the left hallux nail.
- Assessment: Infected toenail on the lateral side of the left big toe, requiring partial avulsion and antibiotic treatment.
- Plan: Perform a partial avulsion on the lateral side of the left big toe to remove the infected part of the toenail, and prescribe antibiotics following the procedure to address the infection.
- Procedure Note:
- Procedure: Partial avulsion of the left big toe.
- Anesthesia: 6 ml of lidocaine used.
- Findings: Infected toenail on the lateral side of the left big toe.
- Treatment: Partial avulsion of the infected toenail and antibiotic treatment.
- Follow-up: Schedule a follow-up appointment to monitor the infection and adjust treatment as needed 2.
From the Research
Soap Note
- Patient: Diego
- Chief Complaint: Infected toenail on the left big toe
- History of Present Illness: The issue has been ongoing for about a month, with a history of clipping nails too short, which may contribute to the problem
- Physical Exam: Infection of the lateral aspect of the left hallux nail
- Assessment: Infected toenail on the lateral side of the left big toe, requiring partial avulsion and antibiotic treatment
- Plan: Perform a partial avulsion on the lateral side of the left big toe to remove the infected part of the toenail, prescribe antibiotics following the procedure to address the infection 3, 4
Procedure Note
- Procedure: Partial toenail avulsion
- Location: Lateral side of the left big toe
- Anesthesia: 6 ml of lidocaine used, as the toe did not become numb initially
- Description: The procedure involved the removal of the infected part of the toenail, with the goal of relieving pain and preventing further infection
- Complications: None reported during the procedure
- Post-Procedure Care: Antibiotics were prescribed to address the infection, and follow-up appointments were scheduled to monitor the patient's progress 5, 6
Diagnosis and Treatment
- Diagnosis: Infected toenail on the lateral side of the left big toe
- Treatment: Partial toenail avulsion, antibiotic therapy
- Rationale: The treatment approach was based on the patient's history of recurrent infections and the presence of an infected toenail, which required surgical intervention to remove the infected tissue and prevent further complications 4, 7