Please write a SOAP note for a 15-year-old patient with acute bacterial cellulitis of the left great toe secondary to an ingrown toenail who underwent partial nail matrix excision in the office.

SOAP Note: 15-Year-Old with Cellulitis of Left Great Toe Secondary to Ingrown Toenail with Partial Nail Matrix Excision

SUBJECTIVE

• Chief Complaint: Left great toe pain, redness, and swelling
• History of Present Illness: 15-year-old presents with ingrown toenail of left great toe with associated cellulitis. Reports pain, erythema, warmth, and swelling around the lateral nail fold. [Document duration of symptoms, progression, any purulent drainage, fever, or systemic symptoms]
• Past Medical History: [Include diabetes status, immunocompromised conditions, previous episodes of ingrown toenails or cellulitis]
• Medications: [Document any antibiotics taken in preceding week]
• Allergies: [Document drug allergies, particularly to beta-lactams]

OBJECTIVE

• Vital Signs: Temperature, heart rate, blood pressure [Note if fever >38.5°C or tachycardia >110 bpm, which would indicate systemic response]
• Physical Examination:
  • Left Great Toe: Erythema, edema, warmth, and tenderness of lateral nail fold
  • Extent of cellulitis: [Document if erythema extends >5 cm from nail edge]
  • Presence of: Purulent drainage, abscess formation, lymphangitis, or regional lymphadenopathy
  • Interdigital spaces: [Examine for tinea pedis, fissuring, scaling, or maceration - important predisposing factor] 1
  • Systemic signs: Alert and oriented, no signs of systemic toxicity

ASSESSMENT

1. Acute bacterial cellulitis, left great toe, secondary to ingrown toenail
2. Ingrown toenail (onychocryptosis), left great toe
3. Status post partial nail matrix excision in office

PLAN

Antibiotic Therapy

For typical cellulitis without purulent drainage or MRSA risk factors, beta-lactam monotherapy is recommended 1. Suitable oral antibiotics include cephalexin, dicloxacillin, amoxicillin, amoxicillin-clavulanate, or clindamycin 1.

• Prescribe: Cephalexin 500 mg PO QID for 5 days 1
  • Duration: 5-day course is as effective as 10-day course if clinical improvement occurs by day 5 1
  • Extend treatment if infection has not improved within 5 days 1

MRSA coverage is NOT routinely needed unless there is penetrating trauma, purulent drainage, or evidence of MRSA infection elsewhere 1. In this case of typical cellulitis from ingrown toenail, MRSA is uncommon and beta-lactam monotherapy is appropriate 1.

Surgical Site Management

Following partial nail matrix excision:

• Wound care: Keep clean and dry, daily dressing changes
• Elevation: Elevate affected foot to promote drainage of edema 1
• Monitor for surgical site infection: Watch for increased erythema >5 cm from wound edge, fever, or purulent drainage 1

Note on postoperative antibiotics: While postoperative infection rates after nail matrix excision can be elevated (up to 18.9% in some studies 2), systemic antibiotics are already being given for the cellulitis. The evidence shows oral antibiotics before or after phenolization do not improve outcomes 3, and adjunctive antibiotics are not routinely indicated for surgical site infections unless there is significant systemic response 1.

Predisposing Factor Management

Critical to prevent recurrence 1:

• Treat toe web abnormalities: Examine and treat any tinea pedis, fissuring, or maceration between toes 1
• Proper nail care education: Instruct on correct nail trimming technique
• Footwear modification: Avoid tight-fitting shoes
• Manage hyperhidrosis if present

Follow-Up

• Return in 5 days to assess clinical improvement and determine if antibiotic extension needed
• Return sooner if worsening erythema, fever, increased pain, or systemic symptoms develop
• Long-term: Monitor for recurrence (overall recurrence rate after initial surgery is 19.5% 4)

Patient Education

• Warning signs: Return immediately for fever, spreading redness, red streaks up leg, or worsening pain
• Elevation: Keep foot elevated as much as possible
• Activity: Limit weight-bearing activities until cellulitis resolves
• Recurrence prevention: Proper nail care and footwear are essential

Clinical Pearls

• Cultures are unnecessary for typical cellulitis cases 1
• Inflammation may worsen initially after starting antibiotics due to pathogen destruction releasing inflammatory enzymes 1
• Preoperative antibiotics may reduce recurrence: Use of antibiotics within the week before surgery was associated with lower recurrence rates (OR 0.5) 4