Video instructions and help with filling out and completing Which Form 2220 Exclude

Instructions and Help about Which Form 2220 Exclude

So our next speakers are dr. del Rosso who we heard from earlier this morning and also dr. Bonnie halusky from the University of Alabama burning Birmingham dr. ellu ski has one of our colleagues working in her lab actively doing Studies Wendy Cantrell did Wendy make it yeah no okay so okay good morning everybody I'm Bonnie a loose key from Birmingham Alabama not Michigan and we're gonna talk Jim and I are going to do a little duo here on improving your diagnostic skills simple office tests so I'm gonna go first and I'm gonna talk about three things we're gonna talk about the diagnosis of onychomycosis we're gonna talk a little bit about what to do in psoriasis and third we're going to discuss something that itches scabies so let's first met talk about onychomycosis so onychomycosis begins as an extension of tinea pedis fungi don't just go from the carpet and pole-vault into your toenails they actually first make a home on the bottom of your foot and cause tinea pedis so the first thing you have to do is look for tinea pedis and that's exactly why when we look at onychomycosis the fungus the abnormality is in the distal region of the nail in the region of the hypo Nikki because the fungus enters here from the bottom of the foot and extends from the distal to the proximal area and I kind of drew here the amount where the fungus is living happily in a nail and that patient has distal subungual onychomycosis and that's important to know because every drug we have to treat onychomycosis is treating this type distal subungual onychomycosis also known as distal lateral subungual onychomycosis and this these are more slides showing distal or distal lateral subungual onychomycosis again you will see the annika lysis and the distal region of the nail you will see subong keratosis maybe a yellow color or maybe a brown color and these patients have generally have or had tinea pedis this is another patient also a distal annika lysis as is this patient and this is pretty white and that actually is the beginning of a fungal abscess also known as dermatophytosis but it's a sign that it's going to be hard to treat so when you go to figure out how to diagnose the patient the first thing you need to do is look for tinea pedis so look in the toe web and look at the bottom of the feet if they don't have tinea pedis they probably don't have onychomycosis with a couple exceptions maybe they had tinea pedis and treated it before that's quite possible or two perhaps they had a pedicure and the instruments used to clip the nail were contaminated so the fungus was inoculated into the nail by contaminated instruments so that could be in one explanation for no tinea pedis without onychomycosis so the first strategy confirmed tinea pedis and then you want to do a diagnostic test and i think doing these diagnostic tests will become more important because we have two new topical drugs for onychomycosis which i'll talk about this afternoon f anicon is all and talib oral and i think we're going to need to have conclusive proof of infection prior to prescribing these drugs this may be required by most insurance providers so you have three things you can do a Koh you can do a fungal culture or you could do nail clippings so how do you obtain your sample well first thing first we want to clean the nail with alcohol and often I have to add I clean the nail with soap and water now why do I clean the nail because there's bacteria living in the nail and the bacteria if you're doing a fungal culture will over grow and prevent the growth of the fungus so you want to remove the bacteria so clean with alcohol soap and water whatever you need and then you clip the disease distal part of the nail plate and use a curette to remove the debris from nail bed this is the instrument I use to clip the nail these are our nail nippers dual action nail nippers they're well worth an investment they're easy to do even for the thickest of nails because of their dual action you can clip very easily and get your nail specimen and after you did clip the nail off you will expose the nail bed and then you can obtain debris if any from under the nail bed and to obtain the debris I use a small little curette it doesn't hurt you just kind of scrape the nail bed with a curette if you don't have a little correct well you could use a disposable correct this is us very small one millimeter correct or you could use a 15 blade but you have to be very careful with that of course alright once you obtain your specimen you then could if you're planning to do a koh put the specimen on honest slide a glass slide add a coverslip and then you can add your potassium hydroxide solution so what Koh does is it dissolves the cell membranes of the host but it cannot dissolve the cell wall of the - so eventually the cell membrane tissue all dies the cells die leaving only the hyphy you do not need to heat your koh preparation if you're using DMSO so I do like to buy solutions that contain DMSO I also like to have solutions that contain cloris all Blackey because that stains the hyphy a blue-black color which makes it so much easier to recognize under low power and then you look under low power not high power and this is Koh positive you see these small little hyphy that are septate when you look closely under low power and these are coloured because we used clora