Katie Posh runs an upscale nail salon. The service process includes five activities that are conducted in the sequence described below. (The time required for each activity is shown in parentheses):

Activity 1: Welcome a guest. (1 minute)

Activity 2: Clip and file nails. (3 minutes)

Activity 3: Paint. (5 minutes)

Activity 4: Dry. (10 minutes)

Activity 5: Check out the customer. (4 minutes)

Three servers (S1, S2, and S3) offer the services in a workerLpaced line. The assignment of tasks to servers is the following:

S1 does Activity 1.

S2 does Activities 2 and 3.

S3 does Activities 4 and 5.

The drying process does not require server 3’s constant attention; she/he needs to only escort the customer to the salon’s drying chair (equipped with fans for drying). The time to do this is negligible. There exists only one drying chair in the salon.

PN1. Which resource is the bottleneck of the process?

PN2. What is the utilization of server 2? Assume that there is unlimited demand and that the process only admits customers at the rate of the bottleneck.

PN3. What is the average labor utilization of the servers? Assume that there is unlimited demand and that the process only admits customers at the rate of the bottleneck.

PN4. Assume a wage rate of $12 per hour. What are the direct labor costs for one customer?

 

DERMATOLOGY CASE STUDY

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.

Please see below:

Now that you have identified the treatment for onychomycosis and labs for baseline and follow up therapy. For Week 6, 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.