Claire is a 42 twelvemonth old female, with type 2 diabetes Mellitus. Claire has a medical history of high blood pressure and mild nephritic damage. Claire is concerned about her thick xanthous crumbling toenails that affects over 80 per centum of each nails on both pess, and has been presented for many old ages. Claire wants to her toenails to look normal. In this essay I will discourse the pathology around patient ‘s presentation, propose at least four differential diagnosings, a probationary diagnosing and the subsequent on-going direction of their Diabetess Mellitus type 2. I will so analyze what type of trial clinician should order to do a proper diagnosing. I will so discourse and construe the consequences of full blood count, cholesterin degree cheque, Creatinine degrees, 20 % KOH, Gram Staining, and Lacto phenol. Claire is taking a batch of different medicines. These medicine are Metformin 500mg, Glibenclamide 5mg, Accupril 40mg, Probiotics ( three tablets daily ) , St John Wart ( one tablet daily ) , Thompson ‘s Immunoforte ( one time daily ) , Garlic capsule ( 3 capsules daily ) , 2mL of Echinacea with H2O ( 3 times daily ) .


“ Diabetes is a disease characterised by elevated blood glucose degrees. It is an increasing planetary load for healthcare systems, and it is estimated that approximately 7 % of grownups worldwide have the disease ” 200,000 people in NZ with diabetes Ministry of Health, ( 2010 ) . Approximately 85 to 90 % of New Zealanders with diabetes have type 2 diabetes ( New Zealand Guidelines Group. ( 2003 ) . ( Robert G. Frykberg, 2000 ) Describes Diabetes Mellitus type 2 as a metabolic upset ensuing from the organic structure ‘s inability to bring forth or use insulin. Type 2 Diabetes Mellitus can be caused by deficiency of exercising, heredity, fleshiness, intoxicant and smoke Merck Manual, ( 2007 )

Diabetess Mellitus type 2 is more common in Maori and Pacific Islanders so European New Zealanders Diabetes New Zealand, ( 2008 ) Peoples with diabetes mellitus type 2 sometimes develop nerve harm to the pess can do the liner of the blood vass to go thickened. This can take to high blood pressure. This is because thickened blood vass important unequal blood flow to lower appendages. This causes hypoxia ( deficiency of equal O at the tissue degree ) TOTARA ( 2003 ) . One of the most serious is that either the whole, or portion, of your pess can go asleep or insensitive to trouble Diabetes New Zealand, ( 2008 ) .A

In relation to Podiatric direction of the pes, taking history of the patient is really of import. Other things we can make is to analyze an Direct ocular reviews, buttocks for peripheral neuropathy utilizing either 10 g monofilaments or biothesiometer, and assess peripheral circulation, peripheral arterial disease, old amputation, old ulceration ( hazard of perennial ulcer ) or current ulceration ( hazard of amputation ) , structural pes malformation and plantar callosity. ( New Zealand Guidelines Group. ( 2003 ) . Thorough appraisal and direction of the pes wellness position of a individual with diabetes requires probes within the classs dermatological ( skin lesions ) , vascular ( pulsations ) , neurological ( esthesis ) , biomechanical ( including force per unit area and pace ) , morphological, footwear and instruction ( on how to command their diabetes ) Edmonds, E, M. , Foster, VM, A ( 2002 )

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We can look into Claire blood circulation on her pess by making an ankle brachial index ( ABI ) . We will take a systolic reading of the brachial arteria of both weaponries by utilizing a stethoscope and systolic reading of posterior tibial and dorsalis pedis artery both pess utilizing 8 Hz Doppler. By taking the highest the reading of brachial arteria systolic reading and highest reading from posterior tibial arteria and dorsalis pedis. By utilizing an ABI= ankle/brachial the normal scope should be between 0.9-1.2. If Numberss are higher or lower than that it means that, Claire might hold intermittent lameness Doobay, V, A and Anand, S, S, ( 2005 )

Diabetic neuropathy leads to progressive lower-limb musculus wasting, loss of esthesis, cardinal, peripheral and autonomic nervous systems and gait changes that overload pess New Zealand Guidelines Group. ( 2003 ) . The most common oncoming of diabetic devolution is the loss of centripetal map ( heat force per unit area and all right touch ) , furthermore motor neuropathy is besides prevailing impacting the lower limb muscular structure and contractile capableness musculuss which are primary for normal biomechanical map. In add-on, autonomic neuropathy causes devolution in sympathetic and parasympathetic nervous systems doing reduced perspiration production and increased collagen glycation taking to a terrible decrease in articulation mobility. The patterned advance of these co-morbidities can take to ulceration in countries of high plantar force per unit areas ( New Zealand Guidelines Group. ( 2003 )

Diabetess can do nephritic damage ( nephropathy ) . “ Nephropathy is characterized by inspissating of the glomerular cellar membrane, mesangial enlargement, and glomerular induration ” . These alterations can do glomerular high blood pressure and easy diminutions in Glomerual filtration rate National Kidney and urologic Diseases Information clearinghouse ( n.d. ) . “ Hypertension, is a major factor in the development of kidney jobs in people with diabetes. ” Kathleen, D. ( 2010 ) Family history of high blood pressure and the presence of high blood pressure appear to increase opportunities of developing kidney disease. Hypertension besides accelerates the advancement of kidney disease when it already exists. Edmonds, E, M. , Foster, VM, A ( 2002 )

“ The ADA and the National Heart, Lung, and Blood Institute recommend that people with diabetes keep their blood force per unit area below 130/80. ” Kathleen, D. ( 2010 ) ,

High blood pressure can be a cause of kidney disease. Kidney disease can be advancements, due to physical and chemical alterations in the kidney, which can take to increased blood force per unit area. High blood pressure can be treated in early phases are indispensable for people with diabetes. Doobay, V, A and Anand, S, S, ( 2005 )

Differential Diagnosiss


onychogryphosis is referred to inspissating of the nail home base, which appears “ pound ‘s horn-like ” Cohen PR, Scher RK. Aging. Hordinsky MK, Sawaya ME and Scher RK. ( 2000 ) . Onychogryphosis chiefly involves the big toe toenail. Onychogryphosis appears uneven, thickened and stain ( chocolate-brown and xanthous ) . Onychogryphosis is chiefly due to irregular film editing of the nails, injury and improper footwear mention. The cause of onychogryphosis is that nail home base grows upwards and hence perverts laterally towards the 2nd figure Turner, A, W and Merriman, M, L. ( 2005 ) . The way of the nail growing is being influenced by force per unit area from footwear or site of injury on the matrix. In a research it showed us that “ A few patients develop subungual sphacelus due to coerce effects, particularly in the presence of diabetes mellitus or peripheral vascular disease. ” Singh, G. , Haneef, S, N and A, U. ( 2005 ) . Onychogryphosis can be mistaken for Onychomycosis because they both have same type of stain and they both cause the nails to be thickened.


Onychauxis nail is inspissating of the nail Dermnet. N, d.. Onychauxis can be caused by injury, tight places. Onychauxis nails are chiefly found in aged population. Onychauxis is characterised as hyperkeratosis, stain, and loss of nail home base. Onychauxis can do hurting on the nail bed, this is due to thickened nail and acquiring force per unit area from the places Turner, A, W and Merriman, M, L. ( 2005 ) . Due to trouble and force per unit area can be cause Onycholysis, subungual bleeding and increased susceptibleness for Onychomycosis. Anirudh, M. ( 2011 )


Onycholysis is a nail upset. Onycholysis can be “ Endogenous, exogenic, familial, and idiopathic factors can do onycholysis. Contact thorns, injury, and wet are the most common causes of onycholysis, but other associations exist. ” Hecker, S, M. ( 2010 ) . .Onycholysis is characterised by separation of the nail home base from the distal free border and progresses proximally. In Onycholysis, the nail home base is separated from the nail bed. Onycholysis is normally characterised as smooth, house, and dry. Onycholysis is ever gets assorted up with Onychomycosis because they both have same presentation Hsu, LM, M. ( 2002 ) . The presentations are nail stain may look underneath the nail as a consequence of infection DermNet New Zealand ( n.d. ) .

Yellow Nail Syndrome

“ Yellow nail syndrome ( YNS ) is a rare upset characterized by a three of xanthous stain and destructive alterations of nails, lymph hydrops and a assortment of pathologies in the respiratory system ” Singh, G. , Haneef, S, N and A, U. ( 2005 ) The xanthous nail syndrome is common in females ( 1:2 ) and occurs chiefly in in-between age adult female Reference. In xanthous nail syndrome they become yellowish- green coloring material, they besides can look thickened and expose an increased longitudinal curvature with some grounds of Onycholysis. Claire can non hold xanthous nail syndrome because xanthous nail syndrome is cause by systemic disease Internet Explorer, respiratory disease. Ahmed, E, M and Eltinay F. ( 2009 )


Onychomycosis affects about 5 % of the population worldwide ( Indian diary ) . The rate of onychomycosis additions with age as 15 % to 20 % of the population from 40 to 60 old ages of age, and 32 % of the population from 60 to 70 old ages of age is diagnosed with the status ( Scherer. W. , McCreary. J. , and Hayes. W. 2001 ) . The grounds for the age related addition in onychomycosis can be due to diabetes, longer exposure to pathogenic Fungis, inaction or the inability to cut toenails or keep good pes attention, repeated nail injury and hapless peripheral circulation Elewski, B. ( 1998 ) . Onychomycosis is defined as an infection of the nails by a fungous component and it represents about 18 to 40 % of all major onychopathies and about 39 % of all superficial mycotic infections ( Godoy, P. , Nunes, F. , Silva, V. , Tomimori-Yamashita, J. , Zaror, L. , & A ; Fischman, O. 2004 ) .

Onychomycosis is frequently thought of as a decorative job, nevertheless it has a great impact on the overall good being of the patients wellness ( William P. Scherer, 2001 ) . Onychomycosis is truly difficult to distinguish from Oncycholysis, because they both have same clinical characteristics, e.g. same chocolate-brown coloring material. The most common clinical characteristics of Onychomycosis include stain of the nail home base, hyperkeratosis and toffee nails. Onychomycosis represents a common and complex medical job. ( Arrese. J. , Franchimunt. C. , and Pierard.G 1999 ) . In the past onychomycosis was referred to a nondermatophytic infection of the nail, but it is now used as a general term to denote any fungous nail infection. Elewski, B. ( 1998 ) .

Analysis and Interpret Results ( Laboratory Investigation )

Gram Staining

Gram staining method is used to distinguishing bacteriums species in to Gram- positive and Gram- negative. The bacteriums divide in these two groups are based on the chemical and physical belongingss of their cell wall. By making this trial we can see what sort of bacterial infection is in Claire toenails. After making Gram staining we can look under microscope to calculate out if the bacterial infection is Gram Positive or Gram Negative Gregersen, T. ( 1978 ) . Bacteria that retain the gentian violet dye appears blue/black when observed under microscope it mean the bacterial infection is gram positive. This is because gm positive bacteriums have a high lipoid cell wall. And if we see ruddy color on the cell wall so its means the bacterium infection is gram positive. Rao, S. ( n.d )


KOH Testing is a really easy trial which can be done in a clinic. The KOH 20 % ( potassium hydrated oxide ) trial is conducted to place what type of fungus is implicated in presentation of Onychomycosis in this patient Gregersen, T. ( 1978 ) . Scrapings were put onto a clean glass slide and heated ( non boiled ) . Then 20 % KOH will be added to assist fade out the ceratin so that it is easy to place under direct microscopy. When looking under the microscope if we see hyphae or strands pollen it means the infection is fungous. Gregersen, T. ( 1978 )


The lacto-phenol cotton blue is a mounting medium used in microbiology research labs, chiefly for fixing saddle horses of fungous civilizations. Lacto-phenol cotton blue was added to heighten microscopy. The sample was so examined under direct microscopy. Is a tool we can utilize to find if the nail sample contains any fungous elements.

Complete blood count

I will state Claire to acquire a full blood trial because from this we can see if Claire is taking attention of diabetes and to look into if Claire has any infection in the organic structure. Red blood cells ( which carry O ) White blood cells ( which fight infection ) , Haemoglobin, ( the oxygen-carrying protein in ruddy blood cells ) , Hematocrit ( the proportion of ruddy blood cells to the fluid constituent, or plasma, in your blood ) , Platelets ( which help with blood coagulating ) Ohio Health, Believe in we. ( 2011 ) . We will make this trial on Claire merely to see her overall wellness and from this we might establish something which she may non cognize about i.e. anemia. Complete blood count will let to name her nephritic damage and to supervise her nephritic damage Diabetes New Zealand. ( 2010 ) . “ Abnormal additions or lessenings in cell counts as revealed in a complete blood count may bespeak that you have an implicit in medical status that calls for farther rating. ” Ohio Health, Believe in we. ( 2011 )

Creatinine degree

Creatinine degree is a trial to “ mensurate how expeditiously the kidneys remove Creatinine and other wastes from the blood. Low Creatinine clearance indicates impaired kidney map ” Kidney Health Australia. ( 2011 ) . We will make a Creatinine degree cheque on Claire to look into how good or bad Claire renal map is working. This trial will let us to see Creatinine degree in the blood, which can lift due to hapless clearance of Creatinine by kidney. An unnatural high degree of Creatinine in the blood warns us of possible malfunction or failure of the kidneys MedicineNet. ( n.d ) . So hence a standard blood trial will be required on a regular basis to look into the sum of Creatinine degree in the blood. The normal scope for Creatinine degree forA womenA is 0.5 to 1.1 mg/dL ( 38.1-83.9Aµmol/l ) Diabetes Explained ( n.d. )

Cholesterol degree

Cholesterol is a fat which can normally construct up in the arterias. there are two types of cholesterin A individual with diabetes has higher degrees of ‘bad ‘ low denseness lipoid ( LDL ) cholesterin and higher degrees of triglycerides in the blood than people without diabetes Diabetes Australia. ( 2011 ) . This is because diabetes can do thickener of the arterias ( coronary artery disease ) . Peoples like Claire with diabetes tend to hold ‘bad ‘ cholesterin atoms that stick to arterias and damage their walls more easilyA MedicalBlog. ( 2010 ) . We will make a cholesterin degree cheque on Claire to happen out how much cholesterin is her blood watercourse and how we can closely associate to the bosom. By cognizing of Claire cholesterin degrees we can see if see in hazard of any bosom status which can impact her in the hereafter MedicalBlog. ( 2010 ) . By holding higher degrees of cholesterin concentration in the blood it can do the arterias narrow and consequences in cut down blood flow, which may ensue bosom status Kidney Health Australia. ( 2011 ) . Due to contracting of the arterias it will do cholesterin to roll up in the arterias doing a encirclement which may take myocardial infarction or a bosom onslaught. This is due to miss of blood flow traveling to the bosom hence less oxygen going to the bosom and remainder of the organic structure. The normal cholesterin degree in the blood should be less than 5mmol/l. Diabetes Australia. ( 2011 )

Pharmacological intercession ( ie. drug interaction, pharmacodynamics, safe dosage )


Metformin 500mg is given to the people with Diabetes Mellitus Type 2. This is because Metformin causes an addition in peripheral consumption of glucose by increasing the efficiency of available insulin. Metformin should be careful given to the people like Claire who has nephritic damage, because medsafe Tells that Metformin can increase the opportunities of nephritic failure or nephritic disfunction. This because Metformin is non metabolised hepatically ( does n’t metabolised by liver ) and excretes unchanged by the kidney. Medsafe. ( 2009 ) . Garlic can do possible hypoglycemic consequence of insulin. Garlic is often used in the intervention of diabetes, randomised tests were done on persons with and without diabetes, and the surveies have non demonstrated any clinically important difference on blood glucose or insulin sensitiveness Owen, J. A. ( 2005 ) .

Glibenclamide 5mg

Glibenclamide is a “ unwritten hypoglycemic agent, acts ab initio on the operation beta cells of the pancreas to let go of insulin. ” Medsafe. ( 2009 ) . Glibenclamide works chiefly by exciting the cells in the pancreas that produce insulin. These cells are called beta cells. Glibenclamide causes the beta cells to bring forth more insulin. This helps to diminish the sum of sugar in the blood of people with type 2 diabetes

Accupril 40mg

Accupril is used to take down high blood force per unit area ( high blood pressure ) Medsafe. Accupril is an angiotensin-converting enzyme ( ACE ) inhibitor. ACE is of import is convert angiotonin I to angiotensin II. This is of import to vasoconstrictor blood vass. The effects of Accupril in cut downing high blood pressure is chiefly primary by suppressing the ACE in tissues to go in the blood go arounding system hence cut downing production of angiotonin II Medsafe. ( 2010 ) .. The suppression of production of angiotonin II can excite the secernment of aldosterone from the adrenal cerebral mantle, thereby easing nephritic Na and unstable resorption Medsafe. ( 2010 ) .. Peoples who are taking Accupril or any ACE inhibitor are advised to non to hold high diet of K. This because of “ Reduced aldosterone secernment by Accupril may ensue in a little addition serum K. ” Therefore doing hyperkalemia Medsafe. ( 2010 ) . Garlic has been found lower blood force per unit area and may theoretically potentiate the effects of hypotensive agents. There has been not clinical hypotension associated with attendant usage of Allium sativum and antihypertensive agents.

Probiotics ( three tablets daily )

Probiotics are: “ Live micro-organism which when administered in equal sums confer a wellness benefit on the host ” WHO. A Peoples enduring from irregularity, diarrhea, yeast giantism and urinary piece of land infections may besides benefit.A

St John Wart ( one tablet daily )

St John ‘s Wart is frequently used as an antidepressant for mild to chair depression and a ataractic ( Owen, 2005 ) . The common side effects of utilizing St John Warts are concern, dry oral cavity, sickness, GI disturbance and drowsiness Halushka, V. P ( 2009 ) . St John warts is metabolised by the Cytochrome ( CYP ) enzymes. Initiation of the CYP enzymes can take to diminish in plasma degrees of the drug ensuing in cut down in efficaciousness and inauspicious effects. Because Claire is taking Echinacea which is another immune supporter, Echinacea can diminish the map of CYP enzymes in the liver Gorski J. C et Al. ( 2004 ) . which may take to toxicity of St John Warts in the organic structure. The inauspicious reaction can be serious the symptoms can be deficiency of coordination, hyperreflexia, agitation, coma, confusion, shudder, febrility, sickness and diarrhea. Halushka, V. P ( 2009 )

Thompson ‘s Immunoforte ( one time daily )

Thompson ‘s Immunoforte is given to the people to hike their immune system. . Thompson ‘s Immunoforte besides contains Zinc and is used as an immunostimulator and is successful for handling the common cold ( Thompsons Nutrition Ltd, 2009 ) . There are no side effects or any drug interaction with Claire ‘s medicine.

2mL of Echinacea with H2O ( 3 times daily )

Echinacea is chiefly is used for the intervention of the common cold, coughs, bronchitis, grippe and redness of the oral cavity and throat Gorski J. C et Al. 2004.. the benefit of utilizing Echinacea is in the intervention of infection is really effectual of import due to its ability to excite the immune system. Gorski J. C et al. 2004. Echinacea can suppress the metamorphosis by diminishing the map of Cytochrome P450 enzyme ( CYP450 ) . So hence Echinacea can interact with some of the drugs which are metabolised CYP450 enzyme. The drugs which are metabolised with CYP450 can be from one of these groups ‘ immunosuppressors, decoagulants, Ca channel blockers and benzodizeoines Gorski J. C et al. 2004.


A topical antimycotic therapy would likely be suited for this patient due to the superficial nature of the nail infection. Topical intervention should foremost be considered for the patient before surgical intercession is commenced. Because 80 per centum of Claire both pess toenails are affected surgery wo n’t be an option.

Nystatin= topical readyings are indicated in the intervention of cutaneal or mucocutaneous mycotic infections caused by Candida species

Terbinafine= Broad spectrum anti-fungal drug. At low concentrations it is fungicidal against dermatophytes, Microsporum and Candida barms and can be antifungal or fungistatic against barms, depending on the specific species.

I would urge Nystatin because Nystatin is non absorbed into the systemic circulation from integral tegument and mucose membranes. But the side effects are of this topical usage of Nystatin are Local annoyance and sensitization ( such as roseola, dermatitis, pruritis and combustion )

I would n’t urge Terbinafine because it is strongly bound to plasma proteins, with high drug concentrations roll uping in tegument, hair and nails. There are some side effects, such as concern, disquieted tummy, tegument roseolas, or allergic reactions to ingredients in the medicine. Other side effects ( of a more serious nature ) include: liver harm and bosom failure.

For Claire I would urge tea tree oil. Because it has no side effects, the recommended application is 100 % solution locally BID x 6 months. The instruction we recommend utilizing tea tree oil is that to non touch the toe nail with the liqauer tip, because if Claire touch the toenails with liquer the whole tree tea oil solution will be contaminated and the infection on the toenails will be non able to acquire hole.

The instruction advice we can give to Claire is to keep her diabetes and her high blood pressure. We would state Claire to acquire her blood force per unit area look into every 3 hebdomads.


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