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.

________________________________________________________________

Please see below:

      Diagnosis: onychomycosis and labs for baseline

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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