Assignment: Dermatology Cases
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DERMATOLOGY CASE STUDYChief complaint:Â Â â€œ My right great toe has been hurting for about 2 months and now itâ€™s itchy, swollen and yellow. I canâ€™t wear closed shoes and I was fine until I started going to the gymâ€.HPI:Â E.D a 38 -year-old Caucasian female presents to the clinic with complaint of pain, itching, inflammation, and â€œyellowâ€ 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. Â 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 Â AF cream and it did not help relief her symptoms. She has not tried other remedies. Denies associated symptoms of fever and chills.Â PMH:Diabetes Mellitus, type 2.Surgeries: NoneAllergies:Â AugmentinMedication: Metformin 500mg PO BID.Vaccination History: Â 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.Â 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:
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