INSTRUCTIONS: Discussions require a response to a specific question(s), which results in a collaborative conversation(s) and construction of knowledge, which build(s) on and expands your learning in this course. With each discussion, you can support your postings and responses with specific references to the assigned course readings and websites. Post your initial response to the discussion question(s) by no later than today (Sunday), September 18, 2022 at 11:59 pm Pacific Standard Time (PST). With proper citation and reference list in APA format. Substantive first reaction to two other posts is due by Wednesday on September 21, 2022 at 11:59 pm (PST). With proper citation and reference list in APA format. Substantive reply to the reactions to your posts are due by Friday on September 24, 2022 at 11:59 pm (PST). Write a conclusion of your posts by Sunday, September 27, 2022 at 11:59 pm (PST). Answer the questions with proper citations in APA format. Provide a reference list. CASE STUDY 1 CHIEF COMPLAINT “Thick, yellow toenails.” HISTORY of PRESENT ILLNESS A 64-year-old woman presents for her monthly check-in appointment. She has several chronic conditions that are well controlled through medications, and she follows up with specialists involved in her care every 6 months. She is having surgery for a right rotator cuff tear later in the month and would like to discuss her thick, discolored toenails. She has had a number of health problems in the past 5 years requiring medication adjustments and surgeries, and she believes she is “caught up” enough to get something done about her toenails. She reports her nails are very thick (“I haven’t been able to cut my nails in years”), curled, and yellow. She saw a podiatrist about her hammertoe surgical repair last year, but she did not mention her toenails. She remembers having very “pretty” toenails in her 20s and 30s. She would wear nail polish but stopped at least 20 years ago. She has never injured her toenails, never wore high heels, and does not remember ever having a fungal infection. REVIEW OF SYSTEMS The patient’s ROS is positive for toenail discoloration and malformation. She denies rash or skin lesions on feet, limping, numbness, or tingling. RELEVANT HISTORIES The patient’s medical history is significant for diabetes mellitus type 2, controlled with insulin and diet, and bilateral hammertoe of the great toes. Her surgical history includes a right carpal tunnel repair, bilateral bunionectomies, right shoulder rotator cuff repair, right trigger finger release, left shoulder arthroscopy, and right shoulder repair. She has a long history of chronic pain from rheumatoid arthritis and cervical and lumbar disc herniation, for which she is stable on chronic narcotics. The patient is married and on long-term disability because of multiple health problems. She is sexually active and lives with her husband and a roommate. Her exercise is a daily walk, using a walker, to the end of the driveway. Her family history is unknown as she was adopted as a toddler. ALLERGIES No known drug or food allergies. MEDICATIONS •Lantus 100 units/mL solution, Sig: 60 units at bedtime nightly. •Oxycodone hydrochloride 15 mg tablet, Sig: 1 tab PO q6h PRN for pain. •Sotalol 80 mg tablet, Sig: one tab PO BID. •Rosuvastatin calcium 40 mg tablet, Sig: 1 tab PO QD. •Citalopram 60 mg tablet, Sig: 1 tablet PO QD. •Amlodipine 5 mg tablet, Sig: 1 tab PO QD. •Linagliptin 5 mg tablet, Sig: 1 tab PO QD. •Aspirin enteric coated 81 mg delayed-release tablet, Sig: 1 tab PO QD PHYSICAL EXAMINATION Vitals: T 37°C (98.6°F), P 73, R 16, BP 118/72, HT 171.45 cm (67.5 in.), WT 120.6 kg (266 lbs), BMI 41.04. General: Well-appearing woman, no acute distress, appears stated age, sitting comfortably in chair. Front-wheeled walker near chair. Psychiatric: Mildly anxious. Skin, Hair, and Nails: Skin normal in appearance; no rashes or lesions. Normal hair distribution, thin on top of scalp. Fingernails normal in color, texture, and shape; neatly trimmed to edge of nail bed, no cyanosis/clubbing. Toenails on bilateral feet deep yellow, thickened, and curved inward, extending beyond edge of toe. Head: Normal shape and appearance. Lungs: Clear in all lobes. Heart: RRR without murmur. Neurologic: A&O×3; color, sensation, and movement within normal limits on bilateral legs and feet. CLINICAL DISCUSSION QUESTIONS 1.What is the differential diagnosis? 2.What is the most likely diagnosis? Why? 3.Demonstrate your understanding of the pathophysiology in regard to the most likely diagnosis. 4.Should tests/imaging studies be ordered? Which ones? Why? Think about tests/imaging beyond the primary care setting as well. 5.What are the next appropriate steps in management? 6.Review a credible research article(s) about this diagnosis. Demonstrate your understanding of the prevalence, diagnostic criteria, and treatment options. Include a list of your reference(s). 7.What are the appropriate patient education topics for this case? 8.Think about interprofessional collaboration for this case. Provide a list of specialties or other disciplines and indicate what contribution these professionals might make to managing the patient.
Toenails on bilateral feet deep yellow, thickened, and curved inward, extending beyond edge of toe.
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