Chief complaint: â My right great toe has been hurting for about 2 months and now itâs itchy, swollen and yellow. I canât wear closed shoes and I was fine until I started going to the gymâ.
HPI: E.D a 38 -year-old Caucasian female presents to the clinic with complaint of pain, itching, inflammation, and âyellowâ 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.
Please see below:
Now that you have identified the treatment for onychomycosis and labs for baseline and follow up therapy. For Week 6, 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.
Sample Solution
A variable that is regularly inquired about is numerous fields is sexual orientation. It appears to be productive to comprehend the job of sex in these viewpoints. It would expand the writing and information on the theme and add to the advancement of a more conceptualized model of authority. Investigating the job of OCB and the impact of sexual orientation appears to be pertinent for comparable reasons. The principle inquire about inquiry that will be tended to right now the accompanying: What job does sex play in LMX connections? So as to address this inquiry in enough detail, the accompanying sub-questions will be incorporated: How do pioneer and subordinate sexual orientation impact LMX connections? furthermore, Do pioneer and subordinate sexual orientation go about as a mediator in the connection among administration and hierarchical citizenship conduct? The point of this paper is to give an away from of the right now accessible writing on LMX connections and the job of sexual orientation and OCB. Both subordinate and pioneer sex will be tended to. With the assistance of this writing survey, the exploration addresses will be replied as altogether and plainly as could be allowed. To begin with, the strategy will be examined, giving all the applicable data concerning how the writing was found and dissected. This strategy segment will be trailed by a survey of the writing on LMX connections, the job of sexual orientation in these connections, and sex as an arbitrator for the connection among LMX and OCB. In the conversation, the discoveries of the examinations will be abridged and the exploration addresses will be replied. Following this area, suggestions, impediments, and future research recommendations will be talked about. This paper will end with a short end. Strategy An orderly writing search was done in Google Scholar. The terms utilized in the pursuit machine were “authority”, “LMX”, “sexual orientation”, and “OCB”. The outcomes were arranged by pertinence and not sifted by production date. The initial step of examination was basically perusing the title. On the off chance that the title appeared to be applicable to this audit, the subsequent advance was to peruse the unique. In the event that this demonstrated the article would be>
A variable that is regularly inquired about is numerous fields is sexual orientation. It appears to be productive to comprehend the job of sex in these viewpoints. It would expand the writing and information on the theme and add to the advancement of a more conceptualized model of authority. Investigating the job of OCB and the impact of sexual orientation appears to be pertinent for comparable reasons. The principle inquire about inquiry that will be tended to right now the accompanying: What job does sex play in LMX connections? So as to address this inquiry in enough detail, the accompanying sub-questions will be incorporated: How do pioneer and subordinate sexual orientation impact LMX connections? furthermore, Do pioneer and subordinate sexual orientation go about as a mediator in the connection among administration and hierarchical citizenship conduct? The point of this paper is to give an away from of the right now accessible writing on LMX connections and the job of sexual orientation and OCB. Both subordinate and pioneer sex will be tended to. With the assistance of this writing survey, the exploration addresses will be replied as altogether and plainly as could be allowed. To begin with, the strategy will be examined, giving all the applicable data concerning how the writing was found and dissected. This strategy segment will be trailed by a survey of the writing on LMX connections, the job of sexual orientation in these connections, and sex as an arbitrator for the connection among LMX and OCB. In the conversation, the discoveries of the examinations will be abridged and the exploration addresses will be replied. Following this area, suggestions, impediments, and future research recommendations will be talked about. This paper will end with a short end. Strategy An orderly writing search was done in Google Scholar. The terms utilized in the pursuit machine were “authority”, “LMX”, “sexual orientation”, and “OCB”. The outcomes were arranged by pertinence and not sifted by production date. The initial step of examination was basically perusing the title. On the off chance that the title appeared to be applicable to this audit, the subsequent advance was to peruse the unique. In the event that this demonstrated the article would be>
