Study Case

Chief complaint:   My right great toe has been hurting for about 2 months and now its itchy, swollen and yellow. I cant wear closed shoes and I was fine until I started going to the gym.

HPI: E.D a 38 -year-old Caucasian female presents to the clinic with complaint of pain, itching, inflammation, and yellow right great toe. She noticed that the toe was moderately itching after she took a shower at the gym. She did not pay much attention. About two weeks after the itching became intense and she applied Benadryl cream with only some relief.  She continued going to the gym and noticed that the itching got worse and her toe nail started to change color. She also indicated that the toe got swollen, painful and turned completely yellow 2 weeks ago. She applied lotrimin  AF cream and it did not help relief her symptoms. She has not tried other remedies. Denies associated symptoms of fever and chills. 

PMH:

Diabetes Mellitus, type 2.

Surgeries: None

Allergies: Augmentin

Medication: Metformin 500mg PO BID.

Vaccination History:  Immunization is up to date and she received her flu shot this year.

Social history:

College graduate married and no children. She drinks 1 glass of red wine every night with dinner. She is a former smoker and quit 6 years ago.

Family history:

Both parents are alive. Father has history of DM type 2, Tinea Pedis. mother alive and has history of atopic dermatitis, HTN.

ROS:

Constitutional: Negative for fever. Negative for chills.

Respiratory: No Shortness of breath. No Orthopnea

Cardiovascular: Regular rhythm.

Skin: Right great toe swollen, itchy, painful and discolored.

Psychiatric: No anxiety. No depression.

Physical examination:

Vital Signs

Height: 5 feet 5 inches Weight: 140 pounds BMI: 31 obesity, BP 130/70 T 98.0, P 88 R 22, non-labored

HEENT: Normocephalic/Atraumatic, Bilateral cataracts; PERRL, EOMI; No teeth loss seen. Gums no redness.

NECK: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement.

LUNGS: No Crackles. Lungs clear bilaterally. Equal breath sounds. Symmetrical respiration. No respiratory distress.

HEART: Normal S1 with S2 during expiration. Pulses are 2+ in upper extremities. 1+ pitting edema ankle bilaterally.

ABDOMEN: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses.

GENITOURINARY: No CVA tenderness bilaterally. GU exam deferred.

MUSCULOSKELETAL: Slow gait but steady. No Kyphosis.

SKIN: Right great toe with yellow-brown discoloration in the proximal nail plate. Marked periungual inflammation. + dryness. No pus. No neuro deficit.

PSYCH: Normal affect. Cooperative.

Labs: Hgb 13.2, Hct 38%, K+ 4.2, Na+138, Cholesterol 225, Triglycerides 187, HDL 37, LDL 190, TSH 3.7, glucose 98.

A:

Primary Diagnosis: Proximal subungual onychomycosis

Differential Diagnosis:  Irritant Contact Dermatitis, Lichen Planus, Nail Psoriasis

Special Lab: Fungal culture confirms fungal infection.

   Treatment: terbinafine 250 mg daily x 12 weeks or Itraconazole 200 mg daily x 12 weeks

 For follow up and baseline therapy the labs ordered were:   liver blood test and blood count to determine the ALT and the AST levels  

 Please address the following:

1. Specify when to refer the patient after therapy and why? Provide rationale.
2. According to the recommended guidelines, what are the non-pharmacological approaches to Onychomycosis?
3. Provide patient education. Keep in mind the past medical history of this patient.

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