Emily Overton

Age: 39 years old female

Full Case

Station List
Doctor
Patient
Examiner

Patient’s Data​

Past medical history

  • Type 2 Diabetes Mellitus
  • Depression

Drug and Allergy History

  • Metformin 1g BD
  • Sitagliptin 100mg OD
  • Sertraline 100mg OD
  • No Known Drug Allergy 

Recent notes/consultation

Seen 3 months ago by Louise Ireland, Diabetic Nurse Practitioner. 

Presenting Complaint: Patient attended for a routine diabetes review. Blood tests showed HbA1c level of 52 mmol/mol. 

Examination:  BP 130/80mmHg. Feet check satisfactory  

Plan: continue current medication, reinforce lifestyle measures, and review in 3 months

Patient booked a telephone consultation to discuss some concerns.

Patient's Story (Role player’s brief)

Patient’s Story 

You are Emily Overton, a 39-year-old woman with type 2 diabetes and depression. You have called your GP today because you’ve noticed swelling and redness around your left great toenail, which began 5 days ago.

Opening statement: “Hi doctor, I’ve got some swelling and pain around my left big toenail which started about five days ago and it’s getting worse. I’m quite worried. 

If asked what you are worried about, reply:  You’re worried because you’re diabetic, and you recall being told that foot problems can become serious in people with diabetes and it’s beginning to affect your work as a post woman. 

ONLY SAY BELOW IF ASKED 

The swelling is painful and appears to be spreading slightly towards the tip of your foot. This is a new symptom, and you’ve never experienced anything like this before.

You accidentally hit your toe against a door at home about 5 days ago.

You have no other associated symptoms (e.g., fever, discharge, trauma beyond the stubbed toe, systemic symptoms).

Your blood sugar control hasn’t been great lately, but you are now making an effort to improve your diet.

Social History: You do not smoke or drink alcohol. You live with your husband, and you work as a post-woman delivering letters 

Ideas: You wonder if this might be gout, but you’re not sure.

Concerns: You work as a postwoman, and this is affecting your ability to walk and work. You’re also worried because you’re diabetic, and you recall being told that foot problems can become serious in people with diabetes.

Expectations: You want the doctor to tell you what’s going on and offer some guidance or treatment.

Important note:

Let the doctor know you cannot attend an in-person examination because you are currently preparing to go to the airport, you have a flight to Greece in 3 hours, and you will be away for 2 weeks.

You are open to any suggestions the doctor offers regarding treatment or safety-netting.

Say NO to any other questions asked outside of the details already provided in the scenario. 

Marking Scheme

Data Gathering and Diagnosis 

  • Ask about the exact location of the swelling — whether it’s around the toenail or involves the whole toe (to help differentiate between paronychia and gout; paronychia affects the nail fold; gout usually affects the joint)
  • Ask about the presence and extent of redness (to assess for localised infection or inflammation)
  • Ask about the nature and severity of the pain (to assess functional impact and possible infection)
  • Ask if there is any pus or discharge from the area (to identify signs of bacterial infection such as paronychia or abscess)
  • Ask if she has had any fever or systemic symptoms 
  • Ask if she can move the toe joint (restricted movement may indicate joint involvement such as in gout and septic arthritis)
  • Ask if any other toes are affected (to check for spreading infection or multi-joint involvement)
  • Ask about any recent trauma to the area (paronychia may result from minor trauma)
  • Ask if this has happened before (recurrent attacks are commoner in gout than paronychia)
  • Ask how the symptoms are affecting her daily life and work (to assess functional impact)
  • Ask about diabetes control, recent HbA1c, and self-monitoring (poor control increases risk of foot infections and delayed healing)
  • Ask about any family history of similar joint or foot problems (gout can run in families)
  • Ask about smoking, alcohol intake, and diet (modifiable risk factors for gout and delayed wound healing in diabetics)
  • Ask if she is up to date with diabetic foot checks (important in risk assessment and prevention of complications)

Make a working diagnosis of paronychia, based on localised swelling and redness around the toenail, history of trauma, and absence of joint involvement.

Example of explanation to patient​

Emily, you’re absolutely right that gout can cause swelling and pain in the big toe, and it’s a very common cause of discomfort in that area. However, based on what you’ve described, swelling and redness around the nail bed, and your history of type 2 diabetes, this sounds more consistent with a condition called paronychia, which is an infection of the skin around the nail.

You also mentioned that you accidentally hit your toe against a door about five days ago, and that kind of minor trauma can create a small break in the skin, which allows bacteria to enter and cause an infection like this. That’s another reason why paronychia is the more likely diagnosis in your case.

Paronychia can occur more easily in people with diabetes and may take longer to heal, so it’s important that we treat this early to prevent any complications.

Ideally, I would want to see the toe in person or receive a photo, but I understand that you’re currently preparing to head to the airport and flying out shortly, so that’s not possible right now.

Given your symptoms and the likelihood of infection, I’ll prescribe a course of antibiotics. I can see in your notes that you don’t have any allergies to medication—is that still correct?

If so, I’ll prescribe Flucloxacillin 500mg, to be taken four times a day for 7 days. It’s important to take the full course and monitor your toe while you’re away.

Please try to avoid touching or further injuring the area, and check your foot daily. If you notice spreading redness, increasing pain, pus, or signs the area isn’t healing, seek medical attention, even while you’re on holiday.

When you return, I recommend we book you in with our podiatrist for a follow-up diabetic foot review.

Have a safe and enjoyable trip to Greece, and don’t hesitate to reach out if things change while you’re away

Management

Management

  • Offer a face-to-face appointment to assess the affected foot. If the patient is unable to attend in person, ask her to send clear photographs of the foot to assist with remote assessment.
  • Prescribe antibiotics based on clinical suspicion of paronychia. Confirm allergy status before prescribing. If no allergies, prescribe Flucloxacillin; if allergic to penicillin, consider Clarithromycin.
  • Advise the patient to apply warm moist heat (soaks) to the affected toe for 10–15 minutes, three to four times daily to help reduce pain and swelling.
  • Instruct the patient to keep the area clean and dry to promote healing and reduce risk of further infection. Also advise to avoid trauma or manipulation of the nail.
  • Offer NSAIDs or paracetamol for pain relief, depending on patient preference and contraindications.
  • If the infection is affecting her ability to work (e.g. walking in her role as a postwoman), offer a fit note for time off or suggest amended duties where appropriate.
  • Advise follow-up with the podiatrist for a comprehensive diabetic foot check once she returns from travel.
  • Recommend she ensures she has valid travel insurance for her Greece trip, especially given her underlying diabetes and current foot infection.
  • Safety net: Advise the patient to seek urgent medical attention if she experiences worsening symptoms, such as increasing pain, swelling, redness, discharge of pus, or fever. In the UK, she can call 111 or contact the surgery; if abroad, she should seek help from local urgent medical services.

Learning point from this station: ​

This station highlights the importance of recognising and appropriately managing localised foot infections in diabetic patients, particularly in a remote consultation setting. Patients with type 2 diabetes are at increased risk of foot complications, including paronychia, cellulitis, and delayed wound healing due to underlying vascular or neuropathic changes.

While gout typically presents with sudden onset of severe pain, redness, and swelling at the toe joint, paronychia involves redness, tenderness, and swelling around the nail fold, often following minor trauma.

In diabetic patients, paronychia requires prompt treatment to avoid complications

If a face-to-face review is not possible, remote assessment may be supported by asking the patient to submit a clear photo of the affected area

The case also reinforces the importance of adapting care when patients are unable to attend in person

Further reading