“ 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”. 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. Diabetes Mellitus, type 2. Augmentin Medication: Metformin 500mg PO BID. 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. Both parents are alive. Father has history of DM type 2, Tinea Pedis. mother alive and has history of atopic dermatitis, HTN. 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. Height: 5 feet 5 inches Weight: 140 pounds BMI: 31 obesity, BP 130/70 T 98.0, P 88 R 22, non-labored : Normocephalic/Atraumatic, Bilateral cataracts; PERRL, EOMI; No teeth loss seen. Gums no redness. : Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement. : No Crackles. Lungs clear bilaterally. Equal breath sounds. Symmetrical respiration. No respiratory distress. : Normal S1 with S2 during expiration. Pulses are 2+ in upper extremities. 1+ pitting edema ankle bilaterally. : No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses. : No CVA tenderness bilaterally. GU exam deferred. : Slow gait but steady. No Kyphosis. Right great toe with yellow-brown discoloration in the proximal nail plate. Marked periungual inflammation. + dryness. No pus. No neuro deficit. : Normal affect. Cooperative. : Hgb 13.2, Hct 38%, K+ 4.2, Na+138, Cholesterol 225, Triglycerides 187, HDL 37, LDL 190, TSH 3.7, glucose 98. Proximal subungual onychomycosis Irritant Contact Dermatitis, Lichen Planus, Nail Psoriasis

The patient, E.D., a 38-year-old Caucasian female, presents to the clinic with complaints of pain, itching, inflammation, and “yellow” right great toe. These symptoms began approximately two months ago and have progressively worsened. The patient notes that the itching initially started after she took a shower at the gym, but she did not pay much attention to it at the time. About two weeks later, the itching became intense and she applied Benadryl cream, which provided only partial relief. She continued going to the gym and noticed that the itching got worse and her toe nail started to change color. Additionally, the toe became swollen, painful, and turned completely yellow two weeks ago. The patient tried using lotrimin AF cream, but it did not provide any relief. She denies experiencing symptoms such as fever and chills.

Medical history reveals that the patient has type 2 diabetes mellitus and is currently taking metformin 500mg twice daily. She is a college graduate, married, and does not have any children. The patient consumes one glass of red wine every night with dinner and is a former smoker who quit six years ago. Her father has a history of type 2 diabetes mellitus and tinea pedis, while her mother has a history of atopic dermatitis and hypertension.

Upon physical examination, the right great toe is found to be swollen, itchy, painful, and discolored. The patient does not exhibit any signs of anxiety or depression. Additionally, her vital signs are within normal limits, except for her body mass index (BMI), which indicates obesity. The patient’s head appears normal, with no signs of trauma or abnormalities in her eyes. Her neck is supple, with no palpable masses, lymphadenopathy, or thyroid enlargement. Lung examination reveals clear breath sounds bilaterally and no signs of respiratory distress. The cardiovascular examination shows a regular rhythm, normal heart sounds, and 2+ pulses in the upper extremities. The patient has 1+ pitting edema in both ankles. The abdominal examination reveals no distention, tenderness, or palpable masses. There are no signs of tenderness in the costovertebral angles bilaterally. A detailed genitourinary examination is deferred. The patient has a slow but steady gait, with no signs of kyphosis. The right great toe exhibits yellow-brown discoloration in the proximal nail plate, marked periungual inflammation, and dryness. There is no presence of pus or neurologic deficits. The patient’s affect is noted to be normal, and she is cooperative.

Laboratory results indicate a hemoglobin level of 13.2, hematocrit level of 38%, potassium level of 4.2, sodium level of 138, cholesterol level of 225, triglyceride level of 187, high-density lipoprotein (HDL) level of 37, low-density lipoprotein (LDL) level of 190, thyroid-stimulating hormone (TSH) level of 3.7, and a glucose level of 98.

Based on the clinical presentation and examination findings, the patient’s most likely diagnoses are proximal subungual onychomycosis, irritant contact dermatitis, lichen planus, or nail psoriasis. Proximal subungual onychomycosis is a fungal infection that affects the nail bed and nail plate, leading to discoloration, inflammation, and thickening of the nail. Irritant contact dermatitis is a skin reaction caused by exposure to irritating substances, which can result in itching, inflammation, and discoloration. Lichen planus is an inflammatory skin condition characterized by itchy, flat-topped bumps and skin lesions. Nail psoriasis is a chronic autoimmune disease that affects the nails and can cause discoloration, pitting, and thickening of the nail plate. Each of these conditions has overlapping symptoms, making a definitive diagnosis challenging.

Further investigations, including a nail culture and a biopsy if necessary, may be needed to confirm the diagnosis and guide appropriate treatment. Treatment options may include antifungal medications for onychomycosis, topical corticosteroids for dermatitis, immunosuppressive therapy for lichen planus, or systemic medications for psoriasis. It is also important to address and manage any underlying factors, such as diabetes, that may contribute to the development or exacerbation of these conditions.

In conclusion, the patient’s symptoms of pain, itching, inflammation, and “yellow” discoloration of the right great toe suggest several possible diagnoses, including proximal subungual onychomycosis, irritant contact dermatitis, lichen planus, or nail psoriasis. Further investigation and diagnostic testing are necessary to confirm the diagnosis and guide appropriate treatment.