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.

1. 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:

2. 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

3. 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.

4. 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.