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Focal abnormalities of one nail warrant a culture and sensitivity of any scrapings or exudates from the area, as well as an x-ray of the digit or extremity. A CBC and sedimentation rate will help identify an infectious process. A glucose tolerance test will help identify diabetes mellitus. Careful assessment of the area for vascular insufficiency includes Doppler studies and possibly arteriography. A nerve conduction velocity study and EMG may be necessary if peripheral neuropathy is suspected. A skin or nail biopsy may be helpful.
Routine tests for diffuse nail changes include a CBC, sedimentation rate, chemistry panel, VDRL test, ANA, thyroid profile, chest x-ray, and EKG. Arterial blood gases and pulmonary function studies should be done if clubbing is suspected. Other tests for clubbing will be found on page 82 . Serial blood cultures should be done if subacute bacterial endocarditis is suspected. Trichinella skin test or antibody titer should be done in cases in which there are splintered nails with negative cultures for subacute bacterial endocarditis. Muscle or skin biopsy will be useful not only for trichinosis but also for collagen disease. Nerve conduction velocity studies and EMGs will be helpful in diagnosing peripheral neuropathy.
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
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