Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint:
Document the patient’s main concerns related to the ingrown toenail. This may include:
Pain in the affected toe, often described as throbbing or sharp.
Redness, swelling, and tenderness around the affected nail edge.
Difficulty wearing shoes due to discomfort.
Possible drainage (pus) if infection is present.
History of Present Illness:
Onset and duration of symptoms.
Severity of pain and any aggravating factors (e.g., wearing shoes).
Prior history of ingrown toenails in the same or other toes.
Any recent trauma to the toe (stubbing, dropping object).
Self-care measures attempted (e.g., soaking, home remedies).
Past Medical History:
Underlying medical conditions that may contribute to ingrown toenails (e.g., diabetes, peripheral neuropathy).
History of fungal nail infections.
Family History:
Family history of ingrown toenails (uncommon).
社会史 (shè huì shǐ) Social History:
Occupation requiring frequent use of tight-fitting shoes.
Physical Examination:
Inspect the affected toe:
Identify the involved nail edge (usually the big toe).
Assess for erythema (redness), swelling, and tenderness around the nail.
Look for evidence of drainage or pus if infection is present.
Assess for any deformity of the nail plate.
Check for vascular supply and sensation in the toe (important for diabetic patients).
Laboratory Tests:
Laboratory tests are not typically needed for uncomplicated ingrown toenails.
In rare cases, a bacterial culture may be obtained from drainage if a significant infection is suspected.
Imaging Studies:
Imaging studies are not routinely used for ingrown toenails.
Diagnosis:
Ingrown toenail.
Specify the severity (mild, moderate, severe) based on pain, inflammation, and presence of infection.
分期 (fēn qī) Staging (optional):
Some classification systems categorize ingrown toenails based on severity.
Treatment Plan:
Treatment depends on the severity of the ingrown toenail.
Conservative measures for mild cases:
Soaking the foot in warm water with Epsom salts.
Cotton packing placed under the nail edge to lift it.
Proper shoe selection (wide toe box).
Over-the-counter pain relievers (acetaminophen, ibuprofen).
Partial nail avulsion (removal) for moderate or severe cases:
This is a minor in-office procedure performed with local anesthesia.
A portion of the ingrown nail edge is removed to prevent further ingrowth.
Antibiotics may be prescribed if a significant infection is present.
Prognosis:
Reassure the patient that with proper treatment, most ingrown toenails heal within a few weeks.
Discuss potential complications of neglected ingrown toenails (e.g., cellulitis, infection).
Patient Education:
Proper foot hygiene and nail care techniques to prevent recurrence.
Wearing shoes that fit well and provide adequate toe space.
Trimming toenails straight across, avoiding rounding the corners.
Seeking professional help for ingrown toenail management.
Signs and symptoms to watch for that may necessitate a return visit (e.g., worsening pain, increased redness, fever).