Nursing homework help
DERMATOLOGY CASE STUDY
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 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.
Assessment:
Primary Diagnosis: Proximal subungual onychomycosis
Differential Diagnosis: Irritant Contact Dermatitis, Lichen Planus, Nail Psoriasis
Special Lab:
Fungal culture confirms fungal infection.
As an NP student, you need to determine the medications for onychomycosis.
1. According to the AAFP/CDC Guidelines, what antifungal medication(s) should this patient be prescribed, and for how long? Write her complete prescriptions using the prescription writing format in your textbook.
2. What labs for baseline and follow up of therapy would you order for this patient? Give rationale.
___________________________
According to the AAFP/CDC Guidelines, the recommended treatment for proximal subungual onychomycosis is oral terbinafine or itraconazole for 12 weeks. Given the patient’s comorbidities, terbinafine would be the preferred option. Therefore, the patient should be prescribed Terbinafine 250mg PO once daily for 12 weeks.
Prescription:
Terbinafine 250mg PO daily for 12 weeks
Dispense #84
Refills: 0
For baseline and follow-up of therapy, the following labs should be ordered:
Baseline:
Comprehensive metabolic panel (CMP) to monitor liver function, since terbinafine can cause liver damage.
Complete blood count (CBC) to monitor for anemia and leukopenia, which are potential side effects of terbinafine.
Fungal culture of the affected nail to confirm the diagnosis and identify the specific type of fungus causing the infection.
Follow-up:
CMP at 4-6 weeks after starting therapy to monitor liver function and detect any potential hepatotoxicity.
CBC at 4-6 weeks after starting therapy to monitor for anemia and leukopenia.
Fungal culture of the affected nail at the end of therapy to confirm eradication of the fungus and ensure successful treatment.
Rationale: The baseline labs are important to establish a baseline for liver function and rule out any underlying anemia or leukopenia. Fungal culture will confirm the diagnosis and identify the specific type of fungus causing the infection, which can guide the choice of antifungal agent. The follow-up labs are essential to monitor for potential side effects of terbinafine and assess the efficacy of therapy. The liver function tests are particularly important since terbinafine can cause liver damage. The fungal culture at the end of therapy will confirm the successful eradication of the fungus and ensure a complete cure.
