Comprehensive Study Guide for Podological Clinical History, Pharmacology, and Pathologies

UNIDAD 1: LA HISTORIA CLÍNICA Y EXPLORACIÓN EN QUIROPODOLOGÍA

Quiropodología is defined as the study of pathological processes that can be treated with manual procedures, or with hands handling instruments, to preserve the health of the foot and cure podological conditions. The primary tool for this practice is the Clinical History, which is structured into several fundamental parts.

First, the Datos de Filiación include the patient's full name, date of birth, address, locality, telephone number, and the date of the first visit. This is followed by the Anamnesis, which is divided into sections: the Environment (professional activity, hours spent, type of footwear used) and Sports Activity (frequency and footwear type). The Reason for the Consultation must be recorded literally as the patient expresses it (e.g., "What is wrong?", "When did it start?", "What do you attribute it to?"). Details about pain must be captured: whether it is unilateral or bilateral; the duration in days, weeks, or months; the timing (nocturnal, diurnal, all hours); triggering factors; onset (spontaneous, sudden, gradual); frequency (regular or irregular); character (burning, mechanical pain, inflammatory pain); duration (walking vs. resting); intensity; and the specific path or irradiation of the pain.

Past Medical History (Antecedentes Médicos Personales) requires specific data. For Diabetes Mellitus ($DM$), it is noted if it is Type I or II, duration, and medication. Infectious diseases like HIV or Hepatitis, cardiovascular problems (blood pressure, circulation), and specifically if the patient takes SINTROM are registered. Medications are logged by drug name, dose per take, and frequency (using notation such as $0$ for no, $1$ for yes; $1-1-1$ for every $8\,hours$, and $1-0-1$ for every $12\,hours$). Surgical history (to check anesthesia tolerance), traumatic history (fractures, accidents, sprains that may cause dysmetria), family history (parents/grandparents), podological history (previous visits and reasons), allergies, and other diseases like Alzheimer's or Parkinson's are also documented.

EXPLORACIÓN: INSPECTION AND PALPATION OF THE FOOT

The physical examination occurs in decubitus or sedestation and includes articular, muscular, neurological, and vascular assessments. During inspection and palpation, skin coloration is categorized into: normal pink (non-pathological); waxy white (poor circulation); cyanotic (lack of oxygen, bluish); wine red (capillary hyperemia with increased heat); and yellowish (indicative of hepatic disease). Skin texture involves assessing elasticity (depending on age/health) and hydration. Local temperature is compared across the digital, medioplantar, and talar areas of the plantar face; the digital and medioplantar dorsal face; and the anterior/posterior leg.

Superficial vessels are observed for: Telangiectasias (dilations of small capillaries $1-4\,mm$ in diameter, bright red, may disappear under pressure); Edema (swelling that leaves a mark under compression, representing extravascular fluid accumulation from plasma that can increase body weight by up to $10\%$); and Phlebitis (inflammation of the vein wall appearing red, hot, and painful with shiny skin). Phlebitis is further divided into Phlebotrombosis (the thrombus is poorly adhered and floating, posing a high risk of embolism depending on location) and Thrombophlebitis (the thrombus is fully adhered, obstructing the vein; there is no risk of embolism but a risk of ischemia). Edema due to venous congestion involves poor drainage, thick "orange peel" skin, pain, potential fever, and high risk of pulmonary thromboembolism. Varicose edema is associated with cellulitis and ulcers on the internal side, often caused by footwear compression.

PATHOLOGIES OF THE SKIN, NAILS, AND SWEAT

Dermatopathies include: Ampolla (blister filled with water/serum, should be pierced laterally but the skin must never be removed); Signo de demografía (indicates xerosis or total dryness where one can write on the skin); Eritema (redness from friction); Erosión (wound, loss of skin integrity); Efélice (brown freckle); Flictena (large blister); Habón (elevated itchy bump); Intertrigo (erythematous inflammation in high-friction areas); Mácula (stain that can be white/albina, pigmented, or hyperpigmented); Pápula (circumscribed eruptive elevation like chickenpox); and Vesícula (small blisters that form yellow crusts upon breaking). Keratopathies include Hiperqueratosis (callus), Helomas ("chicken eye" with a deeper core), and Tilomas.

Onychopathies (nail pathologies) are diverse: Beau's lines (transverse grooves from arrested nail growth during illness); Branquioniquia (shortened nail); Anoquia (total or partial absence of nails, often with syndactyly); Coiloniquia (thin nail from water/chemicals); Cromoniquia (discoloration from infection or drugs like minocycline/silver nitrate); Eritroniquia (red longitudinal line); Escleroniquia (thickening and dryness); Hapaloniquia (soft/fragile nails); Hiponiquia (atrophic small nail); Leuconiquia (white nail); Macroniquia (unusually large); Melanoniquia (dark color); Microniquia (small nail); Onicocauxis (thickening with dark/irregular surface); Onicolisis (separation from bed); Onicoatrofia (reduction in size/shape); Onicoclasis (rupture); Onicocriptosis (ingrown nail with inflammation/paronychia); Onicodinia (nail pain); Onicogrifosis (increased thickness); Onicomadesis (proximal detachment); Onicomalacia (softening); Onicorrexis (longitudinal parallel breaks); Onicotomía (removal of a nail piece); Onicomicosis (fungal infection); Oniquia (matrix inflammation); Paroniquia (inflammation of the nail fold); Perionixis (inflammation of the perionychium); Plantoniquia (flat nail); Uña en pinza (twisted); and Uña en pico de loro.

Sweat disorders (Trastornos de la sudoración) consist of: Dishidrosis (altered sweat); Anhidrosis (lack of sweat); Normohidrosis (normal); Hiperhidrosis (excessive); Bromohidrosis (excessive sweat with odor); and Cromohidrosis (colored sweat). Clinodactilias refer to the malposition of the fingers.

PODIATRIC CABINET AND INSTRUMENTATION

The podiatry cabinet should have ventilation, no rugs or curtains, and natural light. It contains: a Podological Chair (rotating $365^{\circ}$, with mobile armrests and separate leg supports); a Stool (5-legged with wheels); and specialized equipment including Micromotors, Aspiration systems, Cold lighting (flexible), Thermal sealers, Autoclaves (for sterilization, ultrasound, and disinfection), Pressure platforms, and X-ray systems.

Basic instruments include: Scalpel Handles ($Mangos\,de\,bisturí$) numbered $3-10$ (most used are $3$ and $4$); Gouges ($Gubias$), either fixed ($1-15$) or interchangeable for handle $3$, used to enucleate helomas or clean nail canals. Burs ($Fresas$) are classified by shape (fissure, cylindrical, pear, flame, olive, etc.), material (tungsten carbide, diamond, carbon steel, ruby, titanium, emery, ceramic), and function (thinning nails or skin). Other tools include Adson, Feilchenfeld, and Halsted forceps, various nail nippers ($Alicantes$), Mayo and Lister scissors, and double-use syringes for air/antiseptics. Consumable materials ($Fungible$) include pure wool felts ($Fieltro$), foam sheets, Moleskin, and Fleecy web. Protective paddings are used to shield areas from anomalous friction.

PHARMACOLOGICAL GUIDE: TOPICAL ANTIBIOTICS AND CORTICOIDS

Topical antibiotics listed include: 1) Midacina® ($Neomicina + Gramicidina$) for inflammatory dermatitis or insect bites. 2) Iruxol-Neo® ($Neomicina + Enzimas\,proteolíticas$) with debriding action, specifically useful for PSEUDOMONAS AERUGINOSA. Note: It is incompatible with Betadine. 3) Iruxol-Mono® ($Clostridiopeptidasa\,A + Proteasa$), used for ulcers in diabetic or bedridden patients. 4) Gentamicina® (aminoglycoside) for pyogenic dermal infections. 5) Ácido Fusídico® for Gram+ bacteria and S. aureus. 6) Mupirocina ISDIN® (Mupirocin) for penicillin-allergic patients. 7) Bactroban® (same as Mupirocin). 8) Terramicina® (Oxytetracycline) for Pseudomonas. 9) Blastoestimulina® ($Neomicina + Centella\,Asiática$) for healing. 10) Dermisone Tri-antibiótica® ($Bacitracina + Neomicina + Polimixina\,B$). 11) Neo-batricin® ($Neomicina + Bacitracina + Zinc\,oxide$) with Lanolin as a protective barrier.

Combining antibiotics with corticoids: 1) Bacisporin® ($Polimixina\,B + Bacitracina + Neomicina + Hidrocortisona$) for dermatitis and intertrigo. 2) Neo-caitrin Hidrocortisona® (prolonged use results in skin atrophy). 3) Diprogenta® ($Betametasona + Gentamicina$). 4) Nesfare® ($Triamcinolona + Framicetina$). 5) Celestoderm® ($Betametasona + Gentamicina$).

Corticoids only: Clovate® ($Clobetasol$), Emovate® ($Clobetasona$), and Vaspit® ($Flucortisona$). Combinations like Beta-Micoter® ($Clotrimazol + Betametasona$) are used for fungal infections such as Tinea pedis. Healing agents ($Cicatrizantes$) include Jaloplast® ($Hyaluronic\,Acid$), Mitosyl® ($Vitamin\,A, D + Zinc\,oxide$), Halibut®, and Ciruplas® (hemostatic gel).

ANTISEPSIS VS. DISINFECTION

Disinfection destroys pathogens on inanimate surfaces, while Antisepsis destroys pathogens on living tissues. Key Antiseptics: 1) Hydrogen Peroxide ($3\%$): Immediate activity, no residual effect, irritant to mucosa. 2) Ethyl Alcohol ($70\%$): Takes $2\,minutes$ to act, null action on organic matter (blood/pus), irritates open wounds. 3) Chlorhexidine Gluconatesolution ($2\%$): Activity in $15-30\,seconds$, active in blood, has a $6\,hour$ residual effect. 4) Povidone-iodine (Betadine): Activity in $3\,minutes$, $3\,hour$ residual effect, delayed granulation tissue formation, used pre-surgery.

Master Formulas ($Fórmulas\,Magistrales$): Iodinated $70\%$ Alcohol (for macerated interdigital helomas), Boric Water ($Agua\,boricada$) for superficial wounds/pseudomonas, Chloramine-T (astringent), and Burow's Water (vascular ulcers).

PODIATRY PRESCRIPTION AND CLINICAL ETIOLOGY

Podiatrists gained prescription rights for specific medications via Law 28/2009. Prescriptions must include the DCI or brand, duration, form, route, and dosage. Clinical etiology in podiatry frequently identifies Gram+ bacteria (Staphylococci, Streptococci) in soft tissue and Gram-, Pseudomonas, or Bacteroides in bone tissue. Systemic antibiotics are justified for patients with fever, deep infections (osteomyelitis), or specific comorbidities.

Regarding pregnancy classifications by the FDA:

• Category A: No risk to fetus in any trimester.
• Category B: Safe in podiatry; no human study risks.
• Category C: Use only if benefit outweighs risk (requires GYN consent).
• Category D: Evidence of human fetal risk; use only in life-threatening situations.
• Category X: Prohibited; risk clearly outweighs benefit.

Common Analgesics:

• Paracetamol: Dose $650 - 1000\,mg$ every $6-8\,hours$; max $4\,g/day$.
• Ibuprofen: High analgesic potential; dose $400 - 600\,mg$ every $8\,hours$.
• Dexketoprofen (Enantyum): High analgesic potential, fast action ($T_{max}: 15\,min$); ideal for post-surgery.
• Omeprazole (Gastric Protection): Justified for patients over $65\,years$, those on anticoagulants, or those with a history of ulcers.

DERMATOLOGICAL CASE STUDIES AND TREATMENTS

Case notes from clinical images provide treatment protocols:

• Repeated trauma hematoma (1st toe): Disinfect with Betadine gel, puncture, and drain; do not trim skin.
• Onychogryphosis: Mill the proximal part of the nail with a bur, avoiding flesh.
• Inclusion Heloma: Enucleate and provide a discharge (padding) of $> 4\,mm$ for max $24\,hours$.
• Punctate Keratolysis: Bacterial infection; treat with Chlorhexidine soap and topical Mupirocin ($2\%$) for $15\,days$.
• Onychocryptosis (Ingrown): Extract spicule and apply antibiotic like Terramicina.
• Psoriasis: Identify by "oil stains" or pitting on the nail; treat with high-potency topical corticoids (Clobetasol) or Urea ($40\%$) master formulas.

THE KERATINIZATION PROCESS AND KERATOPATHIES

The skin serves several functions: Sudoriferous (eccrine/apocrine sweat for thermoregulation), Sensory (Meissner for touch, Krause for cold, Pacini for pressure, Ruffini for deep sensation, and free endings for pain), and Protective. Keratinization is the process where cells mature for $28\,days$ before reaching the stratum corneum. Keratopathies are anomalies in this process.

Congenital types include Ichthyosis (scaly skin) and Palmo-plantar Keratoderma (can be blennorrhagic or arsenical). Treatment involves Chlorhexidine disinfection, softening with Salicylic Vaseline ($10-15\%$), and delamination with a size $10$ (large areas) or size $15$ (small areas) blade. Acquired types result from mechanical stress (pressure/friction).

The evolution of keratopathies follows phases: 1) Sensitization: Redness and slight edema. 2) Vesiculation: Blister formation from friction. 3) Keratosis: Hardening and darkening (core formation in helomas). 4) Subcutaneous Hygroma: Tissue fluid extravasation. 5) Bursitis: Inflamed hygroma, may drain. 6) Tiloma: Thickening without a defined core.

Protocol for delamination: Disinfect, thin the skin from distal to proximal keeping the blade parallel, and enucleate core by holding the blade perpendicular. Follow a specific sequence: plantar area, digital pads ($5^{th} \rightarrow 1^{st}$), interdigital spaces, dorsal digits, lateral zones, periungual zones, and finally talons.

HELOMAS AND OTHER SKIN CONDITIONS

Helomas are characterized by a core resulting from intermittent pressure over a bony point, causing ischemia. Types include:

• Hard Heloma: Dorsal/plantar locations.
• Subungual Heloma: Under the nail, very painful.
• Periungual Heloma: In the nail groove, often from narrow shoes.
• Interdigital Heloma: Most common in the $4^{th}$ space; soft (white) or hard.
• Vascular Heloma: Contains nerve/vessel endings; shows dark/red spots in the core.
• Miliary Heloma: Circular, small, potentially from Vitamin A/D deficiency.
• Inclusion Heloma: Chronic, cystic-fibrotic base in adipose tissue; requires surgical excision.

Other conditions include:

• Talon Negro: Black petechial lesions in athletes, resolves in $3-6\,weeks$.
• Maceration: Softened white skin from moisture; treat with astringents.

VIRAL AND PARASITIC INFECTIONS

Verrugas (Warts) are benign epithelial neoformations induced by HPV. Plantar warts can be Endophytic (single, deep, painful with black spots) or Exophytic/Mosaic (multiple, superficial). Differential diagnosis from helomas: warts hurt upon lateral compression and interrupt dermatoglyphs, while helomas hurt upon perpendicular pressure and maintain dermatoglyphs.

Chemical treatments for warts:

• Mild Acids: Citric, Acetic, Salicylic, and Lactic acids.
• Strong Acids: Nitric acid (Verrutop Isdin), Pyrogallic acid (causes vesiculation), or Monochloroacetic acid (very painful).
• Alkaline substances: Sodium or Potassium hydroxide.

Physical treatments: Cryotherapy with Liquid Nitrogen ($-196^{\circ}C$ for $2\,min$), Histofreer ($-55^{\circ}C$), or CO2 Laser. Medicinal options include Oral Inmunoferon ($6\,capsules/day$) or Lisozima.

Other infections: Larva Migrans (tropical parasite, causes erratic tracts; treat with Oral Albendazole $200\,g$); Escabiosis (Scabies mite; treat with Permethrin or Ivermectin); and Tungiasis (sand flea; requires surgical removal of the flea which progresses through five stages from a red spot to a necrotic black crust).