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.

A:

Primary Diagnosis: Proximal subungual onychomycosis

Differential Diagnosis:  Irritant Contact Dermatitis, Lichen Planus, Nail Psoriasis

Special Lab: Fungal culture confirms fungal infection.

   Treatment: terbinafine 250 mg daily x 12 weeks or Itraconazole 200 mg daily x 12 weeks

 For follow up and baseline therapy the labs ordered were:   liver blood test and blood count to determine the ALT and the AST levels  

 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.

Use APA 6th format

New Health Systems: Aligning Money, Risk, Providers, and Politics.

Discussion Topic: 

Aligning healthcare spending more appropriately across the continuum presents financial and political challenges. Propose a plan to spend more on prevention and less on end-of-life care, and address the political challenges your plan will face.

In 500-750 words, refer at least one article related to your entry from a reputable newspaper (can be online) or other media source that is current within one month and post the link. 

– You must have at least two references in your initial posting, and the media source can be one of the two.  An easy way to find current articles on health policy is through Kaiser Health News.

TURNITIN ASSIGNMENT ! FREE OF PLAGIARISM !

For this assignment, you will complete a testimony regarding the Medicare-for-All proposal that you feel is the best policy approach to behavioral health in terms of benefits, coverage, and consumer cost sharing. If you think that none of the current Medicare-for-All proposals are the best alternative and wish to oppose a particular bill in favor of the ACA or a public option, that is acceptable.

What does the legislation do, what is your opinion and why, and what are you recommending legislators do?

1.  At the beginning of your testimony, state clearly what the legislation does and your position on it. Are you there to speak for it, or against it, or recommend some changes? Do not assume the committee members are familiar with the legislation, so a brief explanation of what the legislation does is needed. 

2.  What is the rationale for your position? For example, why the legislation is needed, or not needed, or why it should be changed and how? In this section, you should provide supporting information for your position, including evidence, statistics, and make other cogent arguments. This should not be just about your opinion or your emotional reaction to a policy issue. You need to back up your position with facts and supporting evidence. 

3. What are its implications for improving health care? Use APA citations and references. Watch the sources you are citing – use credible sources!

4. Make recommendations to legislators on how you want legislators to act in relation to the legislation – oppose or support it; make changes in it, or proceed with caution because of certain concerns with it that you have raised with them.

Guidelines for Written Testimony:

– Three to four (3 – 4) pages long, double spaced, 12 font Times Roman

– Turnitin Assignment (NO PLAGIARISM) !

• After reviewing the FEMA website, select an area that you think is the most helpful for a public health nurse to use. Explain your choice.
• 1page

  Choose a global health issue. For this assignment, you will introduce the health issue and discuss the interventions necessary to prevent the issue and promote health.

Topic: Tuberculosis 

Include the following in your paper:

• Introduction/overview of the health issue and the prevalence in the United States and worldwide
• Contributing factors
• Prevention strategies
• Signs and symptoms
• Diagnostic tests (if applicable)
• Advanced practice nursing role and management strategies
• Medical/pharmacological management (if applicable)
• Follow-up care
• Conclusion

Write a 4 page paper following APA format. You must include 2–3 scholarly sources in your citations and references not older than 2015.