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Posted by Diana Breland on October 11, 1999 at 00:35:15:

hello everyone I was wondering if someone out there could tell me what the standards of care are for diabetics that develope an ingrown toenail, bring it to the attention of the Dr. immediately, get referal to a "specialist"(HMO will only pay for surgeon to remove ingrown toenail of diabetics) for removal of the slightly ingrown toenail, specialist removes the nail, and inspite of argument from the patient does not prescribe antibiotics, tells patient to go home and go on with life, tells pt no precautions are necessary, tells pt to remove the bandages 48 hours later and perhaps pt would prefer to wear a bandage in public as the toe will not look very pretty. 48 hours later bandages are removed and toe is swollen twice it's original size and pt is in pain. Pt places call to specialist office regarding pain and swelling...pt is told "it is all a part of the healing process" and again offers no precautions or medications in this regard. The phone contacts are made two mor times and pt goes back in to see Dr. that removed toenail, he decides at this visit that indeed pt's assessment of sweeling and pain and drainage is an infection, debrides area again, wraps up foot and sends pt home ...AGAIN with out antibiotic s. he was kind enough to give a prescription of Vicodin
for pain inspite of pt's concerns regarding addiction to such drugs,.Pain and swelling continue, fevers intermittenly, and pt seeks help at an Urgent Care facility over weekend as pain is unbearable. Urgent Care Dr. takes one look at the wound and says to pt
"why did'nt you take your antibiotics?" pt responds
"i was never given an anitbiotics " Urgent Care Dr. decides to wrap toe right back up and strongly recommended that pt seethe Dr. that performed this removal first thing Monday morning. he give pt a prescription of Keflex 500 mg qid and tylenol #3 for pain. This is the frist time antibiotics have been introduced and pt decided to see primary care Dr. on Monday, Primary care Dr. takes one look at toe and suddenly calls for the nurse, and wheel chair to take pt to Xray, prior to going Dr. says to pt "I want you to see a good Dr. for this. Dr. H is a good doctor and we will take of this. "pt has xray and a visit with new Dr H. Dr. H assess toe and recomends soaks and elevation of foot...gives instruction of staying off foot as much as possible and see him in one week.
Dr. H cares for pt until it is obvious that MRI is in order, because CRP and SED rate are worsneing.
Mri reveals signs of osteomylitis,Dr.H performs I+D bone biopsy on May 10,1999, Groshong Cather placed May11,1999 and 13 weeks of IV ancef begin, at the end of the first month it is noticed by patient that toe has stopped improving, CRP and SED rate are rising again. more antibiotics are added...no relief...consult with Infectious Disease Dr. regarding clinical picture. Dr. A reveals that the medical team has done everything to stop infection "covered situation with massive amt.s of antibiotics and at this time there are 2 options...repeat I+D and IV TX with stronger antibiotic (vancomycin, gentamyocin, etc..etc...) he also outlines the risks involved with these stronger antibiotics....kidney/liver damage, hearing loss, option2- amputation.
Pt chose amputation after careful deliberation and this was performed Sept 20, 1999. the first joint of the right great right toe was removed.
After reading all of this can someone give me what the standard of care is for ingrown toenails in diabetics and what the treatment should be for pt's that have developed osteomylitis inspite of treatment.
Please..please...respond as soon as possible...
Diana

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