painful and discolored.Psychiatric

painful and discolored.Psychiatric

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 OrthopneaCardiovascular: Regular rhythm.Skin: Right great toe swollen, itchy, painful and discolored.Psychiatric: No anxiety. No depression.Physical examination:Vital SignsHeight: 5 feet 5 inches Weight: 140 pounds BMI: 31 obesity, BP 130/70 T 98.0, P 88 R 22, non-laboredHEENT: 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 onychomycosisDifferential Diagnosis:  Irritant Contact Dermatitis, Lichen Planus, Nail PsoriasisSpecial 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.

Q

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

hypertension ,, diabetes mellitus 2 , salt intake , obesity