NRNP 6531 i-Human Template / Week 2 Case

Management Plan Template

1. Problem Statement

a. How would you present this patient to your preceptor? Include both subjective and objective findings.

· Patient is a 36-year-old female with PMH of Type 2 DM, who presents with multiple annular lesions on her bilateral thighs x 2 weeks that she describes as constantly itchy (6/10), characterized by red raised borders, central clearing, and associated erythema and scaling. Denies fever or systemic symptoms. Denies recent travel, exposure to known irritants, new skin products, skin injuries, bites, or infection. Reports worsening of rash with OTC corticosteroid use. Physical exam reveals that the patient is afebrile; lesions are negative for fluctuance, palpable nodules, vesicles, pustules, discharge, or signs of secondary infection. Risk factors include Type 2 DM diagnosis and participation in hot yoga and indoor swimming, making the presentation concerning for a superficial dermatophyte infection.

2. Primary Diagnosis with coding

a. Primary diagnosis with ICD-10 code:

· Tinea Corporis: ICD-10 Code- B35.4

b. Rationale for primary diagnosis:

· The clinical presentation of an annular, itchy/pruritic rash on the legs with multiple lesions characterized by raised, erythematous, scaly edges with central clearing and exacerbation with topical corticosteroids use aligns with the AAFP guidelines for diagnosing tinea corporis. (Ely et al., 2014)

c. CPT Code for Visit:

· 99213 (Established patient, low complexity visit, problem-focused exam, and decision-making.)

3. Evidence-based guidelines

a. Which guidelines were used to develop the primary diagnosis?

· American Academy of Family Physicians (AAFP) 2014 Clinical Practice Guidelines for diagnosing and managing tinea infections.

4. Differential Diagnoses

a. Include 3 -5 differential diagnoses (different from the primary diagnosis):

· Atopic Dermatitis, Contact Dermatitis, Psoriasis

b. Rationale for each diagnosis:

1. Atopic Dermatitis

· Rationale: Also has erythematous/itchy lesions/plaques, less likely to have active borders or central clearing of lesions that are usually not annular and may be lichenified.

2. Contact Dermatitis

· Rationale: Also has erythematous/itchy lesions/plaques, is less likely to have active borders or central clearing, and lesions are usually not annular.

3. Psoriasis

· Rationale: Psoriasis can present as well-demarcated, erythematous plaques with silvery scales; however, it lacks central clearing, and lesions tend to persist without spreading in an annular pattern.

(Ely et al., 2014)

5. Management Plan: Medications, nonpharmacological treatments, ancillary tests, and referrals:

a. Drug name, dosage, route. Include any supplements or OTC medications. Include education for prescribed medications:

· New Rx: Luliconazole 1% cream, apply cream to affected area and 1-inch surrounding area(s) daily for 1 week.

· Medication Education:

· Emphasize the importance of applying topical medication 1 inch beyond the border of the lesions.

· Emphasize the importance of completing the entire course of the topical antifungal regimen to prevent recurrence.

· Instruct that medication is for topical use only.

· Instruct not to apply over large surface areas due to the risk of increased systemic exposure.

(Medscape, 2024)

· Discontinue OTC corticosteroid cream, as it can worsen tinea infections.

· OTC antihistamines, like diphenhydramine, as needed for pruritus/itching per package instructions.

· OTC antifungal powder for prevention.

b. Nonpharmacological treatment/supportive care:

· Wash affected areas with mild soap and water, and pat areas dry completely before applying topical medications.

· Shower, dry the body completely, and wear fresh/clean clothing immediately after activities like yoga or swimming.

· Aloe Vera can help moisturize and minimize discomfort.

c. Any ancillary testing needed: None relevant to diagnosis.

d. Referrals: None relevant to diagnosis.

6. SDOH, health promotion and risk factors

a. SDOH – After reviewing this patient’s social history, they do not appear to have any significant SDOH barriers, but here are some important factors to consider.

· Economic Stability: Assess the affordability of prescription medications.

· Health Literacy: Ensure understanding of fungal transmission and prevention.

· Environmental Exposure: Discuss hygiene practices in shared public spaces like gyms and pools.

b. Health promotion – include all age-appropriate preventive health screenings and immunizations:

· The patient is currently UTD on the following:

· Immunizations

· Dental cleanings

· Pap smear

· Annual eye exam

· Clinical breast exam

· Additional health promotion screenings needed include:

· Hemoglobin A1C

· Lipid panel

c. Risk factors – Address patient risk factors related to primary diagnosis:

· Type 2 DM: Impaired immune response related to the disease process of DM predisposes patients to increased risk for dermatophyte infections and impaired wound healing.

· Exposure to frequent sweating and moist/humid environments: Frequent participation in hot yoga and swimming increases possible exposure to fungi, increasing the susceptibility to dermatophyte infections.

7. Patient Education

a. Include comprehensive patient education related to the current health visit:

· Educate on Diagnosis: Tinea corporis, commonly referred to as “ringworm,” is a superficial fungal infection of the legs, arms, or trunk that is treated with consistent antifungal therapy.

· Transmission Prevention: Avoid sharing towels, clothing, and gym equipment. Keep skin clean and dry. Frequent hand washing. Avoid scratching affected areas if possible.

· Avoiding Corticosteroids: These medications can worsen fungal/tinea infections.

· Avoiding excessive moisture: Wear loose-fitting, breathable clothing; change/wash clothing and towels frequently.

· Disinfect personal items: Clean yoga mats, gym equipment, clothing, and swimwear to prevent reinfection. Do not share items that have not been disinfected, like towels or equipment. Use a separate towel to dry affected areas to avoid spreading the infection.

· Diagnosis of Type 2 DM as a Risk Factor: Educate on the importance of compliance with disease management and the implications of uncontrolled blood glucose on skin health and its effects on healing, leading to bacterial infections and increased risk for fungal infections.

8. Follow up

a. Include time for the next visit and specific symptoms to prompt a return visit sooner:

· Routine Follow-Up: Schedule in 2 weeks to assess treatment response.

· Return Sooner If (Red-Flag symptoms):

· Symptoms worsen despite treatment.

· New lesions begin to develop.

· Presence of fever, or if any lesions develop signs of infection like excessive redness, swelling, pain, warmth, or drainage. Go to the emergency room if symptoms are severe.

· Any adverse reaction to prescribed medications. Go to the emergency room if symptoms are severe, like throat swelling or shortness of breath.

9. References

Ely, J. W., Rosenfeld, S., & Stone, M. S. (2014). Diagnosis and Management of Tinea Infections. American Family Physician, 90(10), 702–711. https://www.aafp.org/pubs/afp/issues/2014/1115/p702.html

Luzu. (2024, July 15). Medscape.com. Accessed on March 8, 2025, from https://reference.medscape.com/drug/luzu-luliconazole-999891

Dermatophyte (tinea) infections. (2025). Uptodate.com. Accessed on March 8, 2025, from https://www.uptodate.com/contents/dermatophyte-tinea-infections?search=tinea%20corporis&source=search_result&selectedTitle=2%7E43&usage_type=default&display_rank=2#H18300298

Yee, G., Aboud, A. A., & Syed, H. (2025, February 14). Tinea Corporis. StatPearls. https://www.statpearls.com/point-of-care/30206#History%20and%20Physical

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