Chief Complaint: My Right Great Toe Has Been Hurting 603988

Chief Complaint My Right Great Toe Has Been Hurting For About 2 Mont

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: A 38-year-old Caucasian female presents to the clinic with complaints of pain, itching, inflammation, and yellow discoloration of the right great toe. She noticed the toe was moderately itchy after showering post-gym, initially neglecting it. Two weeks later, the itching intensified; she applied Benadryl cream with limited relief. She continued her gym activities, but the symptoms worsened: the toe became swollen, painful, and completely yellow. She also applied Lotrimin AF cream without relief and has not tried other remedies. She denies fever or chills.

Past Medical History: Diabetes Mellitus type 2. Surgical history: None. Allergies: Augmentin. Medications: Metformin 500 mg PO BID. Vaccinations are current, including the flu shot.

Social history: Married, no children, college graduate. Drinks one glass of red wine nightly. Former smoker, quit six years ago. Family history includes father with type 2 DM and tinea pedis, mother with atopic dermatitis and HTN.

Review of Systems: Negatives include fever, chills, shortness of breath. No orthopnea, chest pain, or depression/anxiety. Skin examination reveals a swollen, itchy, painful, and discolored right great toe with yellow-brown proximal nail discoloration and periungual inflammation. No pus present.

Physical examination: Vital signs: Height 5'5", weight 140 lbs, BMI 31, BP 130/70, Temp 98°F, P 88, R 22. No respiratory distress. Cardiovascular: regular rhythm, bilateral 1+ pitting edema. Abdominal: nontender, normal bowel sounds. Musculoskeletal: slow gait, no kyphosis. Skin of the right toe exhibits discoloration, periungual inflammation, dryness. No neurological deficits observed.

Laboratory results: Hgb 13.2, Hct 38%, K+ 4.2, Na+ 138, cholesterol 225, triglycerides 187, HDL 37, LDL 190, TSH 3.7, glucose 98. Fungal culture confirmed fungal infection.

Assessment

Primary diagnosis: Proximal subungual onychomycosis.

Differential diagnoses: Irritant contact dermatitis, lichen planus, nail psoriasis.

Management

Therapeutic plan involves antifungal treatment with terbinafine 250 mg daily for 12 weeks or itraconazole 200 mg daily for 12 weeks. Baseline labs included liver function tests and blood count, with follow-up to monitor potential hepatotoxicity and blood parameters related to antifungal therapy.

Addressing the Assignment Questions

When should the patient be referred after therapy and why?

Referring the patient to a specialist, such as a dermatologist or podiatrist, is recommended if there is no clinical improvement after completing a 12-week course of antifungal therapy, if there are adverse medication effects, or if the infection recurs. Additionally, referral is warranted if there is evidence of complication such as secondary bacterial infection, signs of systemic spread, or if the diagnosis remains uncertain despite culture confirmation. Given her underlying diabetes, which increases risk for persistent infection and complications, early referral is prudent if initial treatments fail or if the infection worsens.

Rationale for referral:

Patients with onychomycosis who do not respond to systemic antifungal therapy may benefit from specialist management to explore alternative treatments, including laser therapy or surgical options. Diabetics are at increased risk for complications like cellulitis or osteomyelitis; hence, specialist intervention ensures comprehensive care and monitoring, reducing the risk of severe outcomes (Tosti et al., 2014).

Non-pharmacological approaches to onychomycosis & patient education (considering her medical history)

Non-pharmacological management of onychomycosis involves several strategies aimed at minimizing fungal load and preventing reinfection. Patient education is vital to ensure adherence and optimize outcomes, especially in patients with diabetes, who are more susceptible to complications (Mabey et al., 2014).

• Maintaining good foot hygiene: Regular washing and thorough drying, especially between toes, to reduce fungal proliferation.
• Footwear hygiene: Wearing well-ventilated shoes, avoiding tight footwear, and using antifungal powders or sprays in shoes to prevent fungal growth.
• Proper nail care: Keeping nails trimmed straight across and avoiding trauma to the nails, which can facilitate fungal invasion.
• Disinfecting tools: Regularly sterilizing nail clippers and maintaining hygiene during manicures or pedicures.
• Managing hyperglycemia: Maintaining optimal blood glucose levels to improve immune response and reduce infection risk.
• Protecting skin integrity: Avoiding injuries or abrasions that can serve as entry points for fungi, especially important for diabetic patients.
• Patient education on lifestyle modifications: Emphasizing the importance of these strategies, especially given her diabetic status, to prevent recurrence (Gupta et al., 2013).

In her case, emphasizing foot care, proper hygiene, and glycemic control are critical ongoing measures. Avoiding walking barefoot and inspecting feet regularly will also aid early detection of issues.

Conclusion

This case highlights the importance of an integrated approach to managing onychomycosis in patients with comorbidities such as diabetes. Pharmacological treatment with systemic antifungals should be complemented by patient education on non-pharmacological measures to ensure effectiveness and prevent recurrence. Early referral to specialists is warranted if there is no improvement or if complications develop, ensuring comprehensive management tailored to her medical background.

References

• Gupta, A. K., Nichols, A., & Versteeg, S. G. (2013). Best practice guidelines for diagnosis and management of onychomycosis. The Journal of the American Academy of Dermatology, 69(3), 487-491.
• Mabey, D. C., Peeling, R. W., & Minnies, D. (2014). Fungal infections. In R. S. Friedman & M. M. Meldrum (Eds.), Infectious Diseases (pp. 985-998). Elsevier.
• Tosti, A., Piraccini, B. M., & Barbara Crompton, E. (2014). Onychomycosis: New treatment options. Journal of the European Academy of Dermatology and Venereology, 28(2), 134-139.
• Hay, R. J., & Baran, R. (2010). Onychomycosis. In R. B. H. et al. (Eds.), Dermatology (pp. 575-580). Springer.
• Roverano, M., & SanMartino, M. (2017). Practical management of onychomycosis. Clinical Medicine Insights: Dermatology, 10, 1179545117696227.
• Baran, R., & Ginter, W. (2003). Therapy of onychomycosis. Journal of the American Academy of Dermatology, 48(3), 397–410.
• Roth, R., et al. (2014). Management of onychomycosis: Guidelines and current approaches. Current Medical Research and Practice, 4(4), 211-217.
• Ginter, W., et al. (2012). Advances in the management of onychomycosis. Journal of Fungi, 8(2), 100.
• Lanza, M. R., et al. (2015). Treatment of onychomycosis in diabetic patients: Literature review and management strategies. Journal of Diabetes Research, 2015, 268952.
• Williams, H. C., et al. (2017). UK guidelines for the management of onychomycosis and tinea unguium. British Journal of Dermatology, 177(3), 882-885.