What is the best course of treatment for a patient with a painful corn on the plantar surface of the right foot, red and inflamed Metatarsophalangeal (MTP) joint, onychomycosis affecting all toenails bilaterally, and a cyst on the back of the neck?

SOAP Note and Podiatry Referral

SUBJECTIVE

• Chief Complaint: Painful corn on plantar surface of right foot beneath second toe, present for several months with progressive worsening
• History of Present Illness:
  • Sharp, localized pain with weight-bearing and walking that improves with rest
  • Hard, raised center causing significant discomfort when wearing shoes/walking
  • Patient has been self-treating at home using a file and "cutting" the area
  • No previous professional treatment
  • Regular use of tight-fitting sneakers
• Associated Findings:
  • Red and inflamed second MTP joint from chronic pressure/bunion
  • Onychomycosis affecting all toenails bilaterally
• Additional Issue:
  • Cyst on back of neck (recurrent)
  • Previously prescribed doxycycline but patient unsure if picked up
• Past Medical History: No diabetes, peripheral vascular disease, or neuropathy

OBJECTIVE

• Right Foot Examination:
  • Plantar corn beneath second toe with hard, raised center
  • Second MTP joint: erythema and inflammation consistent with chronic pressure
  • All toenails bilaterally: clinical appearance consistent with onychomycosis
  • Evidence of patient self-debridement attempts
• Neck Examination:
  • Cyst present on posterior neck

ASSESSMENT

1. Plantar corn (heloma durum), right foot, second toe - likely secondary to biomechanical abnormality and inappropriate footwear
2. Second MTP joint inflammation, right foot - chronic pressure/bunion deformity
3. Onychomycosis, bilateral feet - affecting all toenails
4. Epidermal inclusion cyst, posterior neck (recurrent)

PLAN

Right Foot Issues (Corn, MTP Inflammation, Onychomycosis):

Immediate Management:

• Cease all self-debridement immediately - patient's home "cutting" increases risk of infection and tissue damage 1
• Footwear modification: Discontinue tight-fitting sneakers; recommend properly fitted shoes with adequate toe box to reduce pressure on second toe and MTP joint 1

Referral to Podiatry - URGENT:

• Professional debridement of plantar corn using conservative scalpel technique to remove hyperkeratotic tissue without causing underlying skin damage 1
• Biomechanical assessment to identify pressure distribution abnormalities contributing to corn formation 1
• Pressure redistribution and cushioning interventions to prevent corn recurrence 1
• Assessment and management of second MTP joint deformity/bunion to address chronic inflammation
• Professional nail care for onychomycosis management, including proper trimming and debridement 1

Onychomycosis Treatment:

• Confirm diagnosis with KOH preparation, fungal culture, or nail biopsy prior to initiating systemic therapy 2
• First-line systemic therapy: Oral terbinafine 250 mg daily for 12 weeks for toenail onychomycosis 1, 2
  • Baseline liver function tests (ALT, AST) and complete blood count required before initiating therapy 1, 2
  • Monitor for hepatotoxicity, taste disturbance, and skin reactions 1, 2
  • Expected mycological cure rate approximately 70% at 48 weeks (12 weeks treatment + 36 weeks follow-up) 2
  • Mean time to overall success approximately 10 months due to slow nail growth 2
• Alternative if terbinafine contraindicated: Itraconazole 200 mg daily for 12 weeks continuously, OR pulse therapy 400 mg daily for 1 week per month for 3 pulses 1, 3
  • Take with food and acidic beverages for optimal absorption 3
  • Monitor hepatic function tests 1

Preventive Measures for Onychomycosis Recurrence:

• Discard old contaminated footwear or decontaminate with naphthalene mothballs in sealed plastic bag for minimum 3 days 1, 3
• Apply antifungal powders (miconazole, clotrimazole, or tolnaftate) inside shoes regularly 1, 3
• Wear cotton, absorbent socks and change daily 1
• Keep toenails trimmed short and avoid sharing nail clippers 1
• Wear protective footwear in public bathing facilities, gyms, hotel rooms 1

Posterior Neck Cyst:

• Prescribe doxycycline (confirm patient picks up prescription this time)
• Follow-up in 2-4 weeks to assess response
• Consider incision and drainage or excision if no improvement with antibiotic therapy

Follow-up:

• Podiatry appointment: Schedule within 1-2 weeks
• Primary care follow-up: 2 weeks to review lab results and assess medication tolerance
• Long-term monitoring: Assess for onychomycosis recurrence at least 48 weeks from treatment initiation 3

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PODIATRY REFERRAL

Patient Name: [PATIENT]
Date: [DATE]
Referring Provider: [PROVIDER NAME]

Reason for Referral: Painful plantar corn with self-debridement attempts, MTP joint inflammation/bunion deformity, bilateral onychomycosis requiring professional podiatric management

Clinical Findings:

• Painful plantar corn beneath right second toe with hard, raised center causing significant pain with weight-bearing
• Patient has been self-treating with filing and "cutting" - needs education on risks
• Red and inflamed second MTP joint from chronic pressure/bunion
• Onychomycosis affecting all toenails bilaterally
• Regular use of tight-fitting sneakers
• No diabetes, peripheral vascular disease, or neuropathy

Requested Services:

1. Conservative debridement of plantar corn using appropriate technique to avoid overdebridement and tissue damage 1
2. Biomechanical assessment with pressure distribution analysis to identify causative factors 1
3. Pressure redistribution interventions including cushioning and orthotic recommendations to prevent corn recurrence 1
4. Assessment and management of second MTP joint deformity/bunion
5. Professional nail care including proper trimming and debridement of dystrophic nails 1
6. Footwear assessment and recommendations for properly fitted shoes with adequate toe box
7. Patient education on proper foot care, nail hygiene, and prevention of corn recurrence

Current Management:

• Oral terbinafine 250 mg daily for 12 weeks initiated for onychomycosis (pending confirmatory testing)
• Baseline liver function tests and CBC ordered
• Patient instructed to cease self-debridement and discontinue tight-fitting sneakers
• Preventive measures for onychomycosis recurrence discussed

Please provide ongoing podiatric care and coordinate with our office regarding treatment progress.

Thank you for your expertise in managing this patient's complex foot pathology.