Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Discolored nails (white, yellow, brown, or black)
Thickening of nails
Crumbling or brittle nails
Distal separation (nail detachment from the nail bed)
Pain or discomfort in the affected nails (rare)
History of Present Illness:
Onset, duration, and severity of symptoms.
Involvement of fingernails or toenails (or both).
Any recent trauma to the nails.
History of fungal skin infections (e.g., athlete’s foot, ringworm).
Past Medical History:
Underlying medical conditions that may increase susceptibility to onychomycosis
(e.g., diabetes, peripheral vascular disease, immunosuppression).
Previous treatments for onychomycosis (if any).
Social History:
Occupation (some occupations increase risk of fungal nail infections
due to moisture exposure).
History of sharing footwear with others.
Family History:
Family history of onychomycosis (suggests possible genetic predisposition).
Physical Exam:
Dermatologic examination: Assess the appearance of the affected nails
(color, thickness, surface irregularities, detachment from nail bed).
Diagnostic Tests:
Direct microscopic examination with potassium hydroxide (KOH) mount
is the simplest and most common diagnostic test for onychomycosis. A fungal
element seen on microscopy confirms the diagnosis.
Fungal culture: May be necessary in some cases to identify the specific
fungal species involved, especially if KOH mount is negative or if treatment
fails.
Assessment:
Onychomycosis: Confirmed by characteristic clinical features and positive
diagnostic test (KOH mount or fungal culture).
Type of onychomycosis: Can be categorized based on the affected part of
the nail (distal subungual onychomycosis, white superficial onychomycosis,
proximal subungual onychomycosis).
Severity of involvement: Consider the extent of nail discoloration
and nail plate destruction.
Differential Diagnoses:
Consider other conditions that may mimic onychomycosis:
Psoriasis of the nails
Lichen planus of the nails
Trauma to the nail
Plan:
Treatment options: Choice of treatment depends on the type, severity,
and location of onychomycosis, as well as patient factors (e.g., underlying
medical conditions). Treatment options include:
Topical antifungal medications (e.g., amorolfine, ciclopirox,
efinaconazole)
Oral antifungal medications (e.g., terbinafine, itraconazole,
fluconazole) – reserved for severe or extensive involvement
due to potential side effects.
Laser therapy (becoming increasingly used, but long-term efficacy data
is still emerging).
Debridement of affected nails: May be helpful to remove thickened
nail plate and improve penetration of topical medications.
Patient education: Educate the patient about onychomycosis, treatment
options, prognosis, and preventive measures (e.g., maintaining good foot
hygiene, wearing appropriate footwear in public areas).
Follow-up: Schedule regular follow-up appointments to monitor treatment
response and adjust the plan as needed. Cure of onychomycosis can take several
months because the antifungal medications need time to grow out the affected
nail plate.
Prognosis:
pen_spark
Onychomycosis can be a chronic condition. Treatment success rates vary
depending on the chosen therapy and patient adherence. Early diagnosis
and treatment generally improve the chance of a cure.