S: Patient is a 28 yr. Old male with ℅ having a scaly lesion over his left groin area and a painful cut between his big and second toe for the last 3 weeks. Pt denies any Hx of diabetes and any recent fungal infections and any skin Dx such as eczema. Pt denies any recent injury to the foot.
Immunizations: Pt states to be up to date with all immunizations including varicella, measles, mumps and rubella vaccines. Patient states to have received 3 doses of the HPV vaccine before the age of 25
Preventive care: Pt states to participating in an exercise regime that consist of lifting weights 4x/week and on occasion goes on runs
Reproductive Hx: Pt denies having any children
Social Hx: pt states to occasionally drinking alcohol 1-2x/week and states to smoking marijuana 3-4x/month, pt denies any nicotine use
Allergies: NKA, NKFA, NKEA
Medications: Patient denies any medications
Hospitalizations: pt denies any hospitalizations and states no prior surgeries
O: 118/86, 72, 98.3, 18, 99% on RA, pain 6/10 on his foot
A/Ox4. Patient appears to be well kempt and clean, dressed for the weather
Eyes: Pupils are equal, round, reactive to light, No exudates, no hemorrhage
HENTS: Normocephalic, no scars, hearing intact, Oral mucosa pink and moist
Neck: non-tender, no jugular venous distention
Respiratory: Lungs clear to auscultation bilaterally, respirations are even and unlabored, breath sounds equal and unlabored, symmetrical chest wall expansion
Cardiovascular: Capillary refill <3 sec, pulses present in all extremities, no edema, no gallop, no murmur, S1 and S2 present
Gastrointestinal: Bowels sounds in all four quadrants, soft and nontender, non-distended
Genitourinary: No costovertebral angle tenderness.
Musculoskeletal: No abnormalities in gait, no tenderness, no masses
Integumentary: Skin is warm, dry, pink and intact, good skin turgor, no bruises, red and warm scaly lesion over his left groin area, fissure present on the left foot between first and second toes, no discharge, no drainage assessed
Neurological: sensation intact, DTR +2 in all extremities, cranial nerves intact
Further questions to assess: do you participate in any contact sports? Do you wear shoes in the locker room at the gym? Do you practice safe sex? Ever been tested for HIV?
A/P: Diagnosis: Tinea cruris and tinea pedis
Differential Dx: Ringworm
Laboratory: culture of foot wound
Medication: Clotrimazole 1%cream, apply to area BID for 2 weeks on the groin area and 4 weeks on the feet (Zhao et al., 2020)
Follow up: 2-3 weeks if rash has not gone away
The patient should be educated to apply medication as prescribed and to apply the medication for the amount of time stated, even if they are feeling better. The patient can use anti sweat spray for feet since fungal infections like dark, warm and moist areas (Zhao et al., 2020). Household items such as towels and bedsheets should be washed weekly. The patient should be encouraged to wear loose fitted clothing to and to shower and change clothing after any physical activity in order to avoid sweat built up on the skin.
Reference:
Zhao, D., Chen, B., Wang, Y.-T., & Jiao, C.-H. (2020, November 20). Topical clotrimazole cream. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7676513/.
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