CASE PLEASE READ:
Chief complaint:“ My right great toe has been hurting for about 2 months and now it’s itchy, swollen and yellow. I can’t 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 appliedBenadrylcream 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 appliedlotriminAF cream and it did not help relief her symptoms. She has not tried other remedies.
Denies associated symptoms of fever and chills.
PMH:DiabetesMellitus, type 2.
Medication:Metformin500mg 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,TineaPedis.mother alive and has history ofatopicdermatitis, HTN.
Constitutional: Negative for fever. Negative for chills.
Respiratory: No Shortness of breath. NoOrthopnea
Cardiovascular: Regular rhythm.
Skin: Right great toe swollen, itchy, painful and discolored.
Psychiatric: No anxiety. No depression.
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, nolymphadenopathy, 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. Noorganomegaly. Normal contour; No palpable masses.
GENITOURINARY: No CVA tenderness bilaterally. GU exam deferred.
MUSCULOSKELETAL: Slow gait but steady. NoKyphosis.
SKIN:Right great toe with yellow-brown discoloration in the proximal nail plate. Markedperiungualinflammation. dryness. No pus. Noneurodeficit.
PSYCH: Normal affect. Cooperative.
Labs:Hgb13.2,Hct38%, K 4.2, Na 138, Cholesterol 225, Triglycerides 187, HDL 37, LDL 190, TSH 3.7, glucose 98.
Differential Diagnosis:Irritant Contact Dermatitis, LichenPlanus, Nail Psoriasis
Fungal culture confirms fungal infection.
QUESTIONS TO ANSWER:
As an NP student, you need to determine the medications foronychomycosis.
1.According to the AAFP/CDC Guidelines, whatantifungalmedication(s) should this patient be prescribed, and for how long? Write her complete prescriptions using the prescription writing format in your textbook. EXAMPLE of prescription
Vital Medical Center
8300 West Flagler ST suit: 170
Miami, Florida 33144
Patient Name: Raul Mendoza DOB:00/00/0000
Terbinafine (250 mg tablets)
Disp: 90 tablets (ninety)
Sig: Take 1 tablet (250 mg) by mouth once daily for 12 weeks for Onychomycosis treatment.
2.What labs for baseline and follow up of therapy would you order for this patient? Give rationale.
-ANSWER THE 2 QUESTIONS ABOVE IN AT LEAST 350 WORDS, WELL NARRATED.
-APA 6TH EDITION
– 2-3 REFERENCES