Case Study: Herpes Zoster in a patient with CLL



Case Study: Herpes Zoster in a patient with CLLCornelia C. CampbellWashburn UniversitySpecialty Practicum IINU607Dr. Bobbe MansfieldMarch 01, 2012Demographic information A Caucasian female, aged 59 years & 4 months was seen in a primary care setting (this initial encounter is hereafter referred to as PC#1). She presented with a complaint of intractable pain and tenderness over her left buttock, groin and labia majora. Past Medical/Surgical History The patient’s past surgical history includes several lymph node biopsies (needle biopsy x4, and incision-biopsy x1) and a single bone marrow aspiration. Her past medical history is remarkable for:ConcernAge / TimelineOutcome / ImplicationSuspicious skin lesion41 yearsPathology = benign seborrheic keratosisIntra-mammary lymphadenopathy (axillary tail of left breast)54 yearsDeemed secondary to cat scratch injury. Spontaneous resolutionSymptomatic left axiliary lymphadenopathy56 yearsNeedle biopsy & pathology: atypical lymphoid proliferation suspicious of low grade lymphomaOncology consult & staging work-up: Diagnosed with malignant lymphoma, non-Hodgkin, small lymphocytic, CD20 positive – stage 2A.Bilateral, symptomatic axillary & supraclavicular lymphadenopathy57 yearsLymph node biopsies & bone marrow aspiration. Progression to chronic lymphocytic lymphoma (CLL) with peripheral blood lymphocytosisAcute thrombocytopenia secondary to CLL3 months laterStarted chemotherapy: 5 cycles of 3 days each over total of 5 months. Completed chemotherapy 6 months prior to PC#1 encounterIsolated outbreaks of cold sores (herpes simplex 1 virus)11 months preceding PC#1 encounterControlled with systemic Valacyclovir at earliest presentation of symptomsSocial History (including cultural and spiritual considerations) The patient lives on a farm in rural north-eastern Kansas, in a single family home shared with her 62 year old husband of 40 years. The couple is happily married, has lived on the same farm for almost four decades where they raised three children (now adults & all happily married). Their children and seven grand-children live within the state of Kansas; one daughter lives in the same rural district. The patient also has extended family members and many life-long friends who live in the area. She has been a regular, active member of a local church, adheres to the Christian faith and describes her religious devotion as one of her most valued personal resources. She has established a reputation as an adherent, responsible consumer of health care services; she exhibits an active interest and regularly participates in the design of her health care. She is able to make informed treatment decisions and often consults published sources, internet based information sites, and her health care providers to further expand her knowledge and understanding of health related matters. She has established ongoing relationships with the staff and providers at the rural health clinic. The patient’s occupational history includes being the wife of a lifelong farmer and being actively involved in the management as well as manual labor on the farm. She also worked as an administrative assistant at the local school and retired in 2008, ending a 20 year career. She describes her career as being fulfilling as well as stressful at times. The patient’s lifestyle habits include regular physical exercise and well-balanced meals which often include produce from her own garden. She consumes small to moderate amounts of coffee and carbonated beverages, but rarely drinks alcoholic beverages. She denies the use of tobacco products and illicit drugs. She is sexually active in a monogamous, heterosexual relationship and does not use any birth control as she is post-menopausal. She performs regular, monthly breast self-examinations and skin checks. She feels safe at home with no concerns of neglect or abuse and has never suffered neglect or abuse. She consistently wears a seat belt when travelling in a vehicle and uses protective equipment as recommended when engaging in potentially hazardous tasks or manual labor. She received vaccinations against smallpox, polio, varicella and influenza as a child and against influenza, tetanus and hepatitis B as an adult. Family History The patient’s father died at age 67 years of non-Hodgkin lymphoma. He was otherwise healthy. Her mother, who also had a history of type 2 diabetes, hypertension (HTN) and coronary artery disease (CAD), died at age 65 years of a stroke. She has four siblings who are still alive and one brother who died at an early age (5 years old) of a neurologic malignancy (exact nature unknown to the patient). Her two sisters both have type 2 diabetes, and the older sister also has asthma and hay fever. Her oldest brother has CAD and the younger brother is an alcoholic but currently sober. Her grandparents (paternal and maternal) all died of cardiac causes at an older age and to the patient’s knowledge, did not have any other major health concerns. One maternal aunt died of breast cancer in her late middle-age. Please refer to Appendix A (figure 1) for a Genogram. Review of Systems and Physical Examination During PC#1, the patient presented at the rural health clinic with a complaint of intractable pain and increased tenderness over her left buttock, groin and labia majora. A review of symptoms yielded the following information:Constitutional: A good historian with written notes regarding the history of present illness (HPI). Usually able to perform all activities of daily living (ADLs) without assistance but since onset of current illness, has required minimal assistance. Previously able to perform instrumental activities of daily living (IADLs) independently but at this time, is limited in some areas such as driving, shopping and frequently leaving her home.HEENT: No changes in vision, hearing, smell & taste. Wears corrective lenses for reading and driving. No congestion, pain or discomfort of associated structures. No vertigo.Respiratory: No shortness of breath, dyspnea, cough, excretions. Not aware of any abnormal breathing sounds. Cardio-vascular: No chest pain, pressure or discomfort. No palpitations. No syncope. Gastro-intestinal: Slight decrease in appetite but no nausea, vomiting, constipation, diarrhea or bowel incontinence. Unintentional weight loss of 2 lbs in past 3 months. Able to tolerate a regular diet and maintain adequate fluid intake. No excessive thirst or hunger and no early satiety. No hematachezia or melena. Genito-urinary: No incontinence, urge, frequency. Slight dysuria involving perineal skin but not the internal urinary tract. No hematuria. No urinary retention or oliguria. Significant tenderness and pain of left labia majora. No mucosal irritation or dryness. Musculo-skeletal: No changes in strength, range of motion or muscle tone. No joint tenderness or swelling. No recent falls or trauma and no amputations or contractures. Skin: Continued significant tenderness of skin of left buttock, left groin area and now also of her left labia majora. Reports clusters of vesicular rash, mostly scabbed over. Concerned regarding possible new lesions or ulceration of existing lesions. Neurologic: No changes in memory, cognition or reasoning. Occasional headaches – relieved by acetaminophen. Neuralgia and parasthesia of left buttock, groin and labia majora. Psychological: Describes herself as emotionally drained but denies hopelessness, depression, inability to care for self or suicidal ideation. Hematology/Lymphatic: History of Chronic Lymphocytic Leukemia (CLL) with questionable immune-competence. No recent lymphadenopathy on self-examination and no lymph-tenderness. Most recent hematology report (2 months prior) demonstrated normal WBC but mild thrombocytopenia. Current medications: a list of current medications can be found in Appendix B, table 1. History of the present illness The patient presented to the rural emergency department (RED) 10 days prior with a complaint of intense burning pain of the left buttock area radiating into the left groin since 3 days prior. The appearance of several small vesicles on her left buttock, had lead her to believe she might be experiencing an episode of Shingles (Herpes zoster) instead of sciatica-like pain, which had been her first impression. Upon noticing the rash, she self-medicated with a home supply of Valacyclovir 1000mg once on the evening and once on the morning before presenting to the RED. At the RED, she gave a history of previous excellent response to Valacyclovir (when used to treat Herpes simplex viral cold sores). The diagnosis of Shingles (Herpes zoster due to reactivation of the varicella zoster virus, VZV) was clinically confirmed and based on her previous good response to this treatment it was decided to continue with the Valacyclovir 1000mg by mouth every 8 hours for 7 days. She was also started on Lortab 5/325mg 1-2 tablets every 4 -6 hours as needed for pain relief but has only taken limited quantities to reduce intense pain and not to pro-actively manage her pain. During encounter PC#1, the patient reported symptom improvement (rash, burning & pain) up to 4 days prior when she completed the 7 day course of Valacyclovir. Since then she has noticed a gradual return of the burning and pain, with an acute increase noted during the past 24 hours. Despite taking Lortab 5/325mg 1-2 tablets every 4 hours as directed, she is experiencing inadequate pain relief at the time of PC#1. Home remedies that were ineffective included Calmoseptine lotion, Aloe Vera gel and Balmex ointment. Warm sitz baths, Aspercreme and Gold Bond powder aggravated the pain. Pain relief (albeit of varying duration) was achieved through the use of ice packs or cold, moist compresses, wearing no clothes on lower body, and applying Desitin cream and corn starch powder to the affected areas. Physical examination findings included:Vital signs: Temp = 97.2; P = 116; BP = 150/86; Sp02 = 97% on RA; Resp = 18Weight = 161 lbsGeneral: alert, oriented & spontaneously interactive. Mild discomfort while standing, significant pain when sitting down – prefers to stand. Movement guarded. Not disabled with no indication of recent trauma. Appears fatigued at times with occasional grimacing. No fever and malaise. Excellent personal hygiene & self-care. Appropriately dressed in loose-fitting clothes. HEENT: Normocephalic; EOM intact, PERRLA bilaterally, no scleral icterus, lesions or erythema noted. Ear canals patent, TMs non-erythematous & no effusion. Nasal passages patent & free of erythema. Oral mucosa moist & glistening. No lesions, erythema, drainage or halitosis noted. Neck: supple w/o JVD, bruits, thyromegaly, lymphadenopathy, tenderness or swelling. Chest, heart & lungs: Eupneic with inspiratory phase = expiratory phase. Symmetrical chest wall expansion w/o use of accessory muscles. Clear to auscultation & percussion. Slight tachycardia with regular rhythm. S1 & S2 appreciated. No bruits, murmurs, gallops or clicks. Small biopsy scar in left axilla noted. No skin lesions, no lymphadenopathy. Clinical breast exam deferred as per patient’s request. Abdomen: no visible lesions or peristalses. Bowel sounds active in 4 quadrants. No rebound, guarding or tenderness however slight apprehension noted during palpation of lower left quadrant (approaching groin area). No hepatomegaly, no splenomegaly. No bruits, no CVA tenderness. No palpable lymph nodes. Rectal: exam deferred as not reported to be affected by current concern. No symptoms indicative of blood loss. Extremities: no clubbing, cyanosis, edema or lesions. Skin slightly dry on lower legs. Cap refill less than 2 seconds in all extremities. Peripheral pulses present, regular & full. Marked tenderness and guarding in left groin upon assessment of left femoral pulse. Musculo-skeletal: Guarded transfers; slow, cautious gait due to perineal discomfort. No limitations in ROM or muscle strength but detailed exam deferred to limit discomfort. No deformities noted. No amputations. Skin: Clean, warm and dry. Specific to affected regions: Skin over upper half of left buttock normal. Lower medial left buttock presents with two discrete clusters of crusted-over and healing lesions noted on an erythematous base. Confined to left S2 and S3 dermatomes. Does not cross midline. Medial cluster measures 3cm(H) x 5cm(W) on top of 5cm x 7cm area of erythema. Lateral cluster measures 1.5cm (H) x 3.0cm (W) on top of a 3.5 cm x 5cm area of erythema. Skin of left groin area moist & free of lesions & erythema but with marked allodynia (extreme sensitivity to touch). Perineum slightly moist without significant erythema. Good hygiene. White powdery substance noted (corn starch powder). Lateral aspect of left labia majora has two scattered vesicles on erythematous base – not ulcerated, not scabbed, not weeping. Also, 2 small (less than 1cm each) areas of erythema without vesicular rash noted. Mild, ill-defined swelling of these 2 areas, sensitive to touch. Neurological: Alert & oriented x3. Significant neuralgia of S2 and S3 dermatome-associated areas over left lower medial buttock, left groin area and left labia majora – does not cross the midline. Psychiatric: Somewhat depressed affect, occasional grimacing and occasional frowning noted. Denies suicidal ideation / history of suicidal ideation. Appears drained and fatigued. PHQ-2 score =2.Pertinent diagnostic tests Diagnosis of herpes zoster is based on clinical findings, supported by presence of unilateral vesicular eruption with well-defined dermatomal distribution following a painful sensory, dermatome-limited prodrome. Despite patient’s underlying compromised immunity, no atypical lesions or distribution were noticed at this time and further diagnostic tests (viral culture, direct immunofluorescence & polymerase chain reaction essay) were considered unnecessary. In addition to the subjective and objective assessment findings, a complete blood count with auto and manual differential (CBC w/manual diff) was ordered to evaluate constitutional wellness. Significant results included: Hb = 14.0 (N)Hct = 38.9 (N)RBC = 3.98 (N)WBC = 3.8 (L)MCV = 97.8 (H)MCH = 35.1 (H)Platelets = 152 (N)MPV = 5.5 (L)# Baso = 0.1(H)%Baso = 3.6#Lymph = 1.1 (L)%Lymph = 29.7 (N)(Please see Appendix B, table 2 for complete results.) Differential Diagnosis with final diagnosis and rationaleCritical thinking pertaining to differential diagnoses can be summarized as follows:Possible diagnosesReason(s) why included / excluded in final diagnosisHerpes zoster (resolution in progress)Likely but due to pt’s immune-compromised state (CLL) and increase in pain after initial improvement, also at risk for subsequent complicationsPost herpetic neuralgia (PHN)Likely manifestation as complication of zoster – PHN onset as resolution of VZV rash occurs. Immune-compromised pt is at higher risk for this complication. Prodromal neuralgia(of recurrence / refractory flare)Likely: immune-compromised pt’s may have atypical presentation where zoster may breech dermatomal boundaries and/or flare up after initial improvement (due to poor cell mediated immune response) Zoster sine herpeteLikely but rare: atypical presentation in severely immune-compromised host – absence of dermatological signs with visceral involvementContact dermatitis (allergic or irritant)Possible as patient gives history of trying several topical therapies for pain relief and lesion resolution. Bacterial skin superinfection with Bullous Impetigo Likely as complication of VZV in immune-compromised host. Would expect pt to present with fever and/or elevated WBC. Also no pustules, no weeping ulcerations, no yellow, crusted lesions noted. No umbilication of vesicles. Zosteriform Herpes simplex virus (HSV)Unlikely: HSV usually not unilateral presentation and outbreak of skin lesions not preceded by prodromal neuralgia. Molluscum contagiosum (MC)Likely as viral superinfection with higher incidence in immune-compromised hosts. Although MC may affect crural folds & may initially be unilateral, lesions are usually umbilicated (not found in this pt) & MC is not associated with neuralgia (prodromal or progressive). Based upon the clinical presentation of crusted vesicular lesions on a erythematous base following a prodrome of acute, unilateral neuritis; favorable response to initial anti-viral treatment; absence of new vesicular lesions but continuation of neuralgia in affected dermatomal areas, the final diagnoses for the PC#1 visit were determined as: (1) ICD: 053.9: Herpes zoster virus affecting left S2 & S3 dermatomes – resolving, and (2) ICD: 053.13 onset of post-herpetic neuralgia (PHN). An additional diagnosis of (3) ICD: 692.0 contact dermatitis (most likely irritant type) secondary to topical remedies, was made based on the patient’s report of trying several topical treatments and relief-measures, some of which aggravated her pain and discomfort. At the time of PC#1 no signs of bacterial superinfection of the skin manifested but this was noted as an absolute indication for immediate follow-up. Plan of careTreatmentsHerpes zoster – resolving Treatment goals for acute VZV are: (a) to limit the length & severity of symptoms, (b) reduce pain, (c) treat constitutional symptoms, and (d) prevent or limit complications such as super-infections and post herpetic neuralgia (PHN). Administration of antiviral therapy (especially when started within the first 48-72 hours) may shorten the course, limit the severity& decrease the likelihood of PHN in certain patients. In this case, the patient had already received antiviral therapy, Valacyclovir (1,000mg po TID x 7days), appropriately administered at the earliest signs of dermatological involvement (started 10 days prior to PC#1 encounter). A summary of anti-viral agents for consideration can be found in Appendix C, table 1. At the time of PC#1, it was decided not to repeat treatment with an antiviral as no new lesions were manifesting. The patient preferred a “watchful waiting” approach and understood that she was to start a second wave of antiviral treatment (considered appropriate for immune-compromised patients with refractory zoster) at the earliest manifestation of any new lesions. The patient still had an adequate home supply of Valacyclovir available as a large quantity was ordered by her oncologist when she previously presented with HSV cold sores. Investigation of this choice of treatment (Valacyclovir in contrast to Famicyclovir) revealed that despite warnings that Valacyclovir should not be used in immune-compromised patients, it also has an off-label use for the prevention and treatment of zoster in cancer patients. The recommended prophylactic dose is 500mg 2-3 times per day and treatment (for an acute episode) should be 1,000mg po 3 times/day (Turkoski, Lance, & Tomsik, 2010, p. 1925). At doses of 8,000mg per day, it was reported to increase the risk of thrombotic thrombocytopenic purpura and hemolytic uremic syndrome in immune-compromised patients (Turkoski et al., 2010, p. 1924). This potential complication supported CBC as adjunctive diagnostic test to assess for any thrombocytopenia. Pain was treated with hydrocodone/acetaminophen (Lortab). At the time of initial diagnosis in the RED, Lortab 5/325mg (1-2 tablets po every 4 -6 hours) was prescribed for as needed use. The current recommendations for the treatment of acute zoster-associated pain include the use of NSAIDs and opioid analgesics. However, with a history of thrombocytopenia linked to previous NSAID use in this patient, NSAIDs were to be avoided. At PC#1, her prescription of Lortab was refilled and the patient received reassurance that she could safely take up to 8 tablets of Lortab in a 24 hour period (and even up to 10 tablets for a short period of time). She was fortunately spared most constitutional symptoms associated with acute shingles (i.e. malaise, fever and headache) and when these occurred on two separate days, the Lortab successfully relieved these symptoms. Additional options for pain relief are discussed in paragraph II. Post-herpetic neuralgia The recurrence/flare of pain experienced by this patient after initial symptom improvement renders this common complication of VZV is of special concern in this case. Factors linked with increased occurrence of PHN include old age, severity of prodromal pain, and severity of pain in the initial, acute episode. Prophylactic VZV vaccination, timely initiation of anti-viral therapy, and certain pharmacological agents (supported in limited studies) have been suggested to prevent the development of PHN. Several options exist for the treatment of PHN. Those taken into consideration for this patient are listed in Appendix C, table 2 (oral administration) and table 3 (topical preparations). During PC#1, the patient, primary care provider and FNP student came to the agreement that the patient would continue treatment of pain with oral Lortab but that she would increase dosing above what she has been using in order to effectively and pro-actively manage her pain. Additionally the patient also preferred to continue with the application of topical remedies and a variety of symptomatic measures (see Appendix C, table 4). It was also agreed upon that Gabapentin would be considered as the next line of pharmacologic treatment to address the PHN if more conservative treatments fail to provide adequate relief. Contact Dermatitis Reporting several trials with a variety of non-prescription topical remedies (listed in Appendix C, table 4), a mild case of contact dermatitis (most likely, irritant dermatitis) was suspected and to avoid any further irritation to the area, it was opted not to prescribe any pharmacological treatment. Instead, the patient received instruction to wash the affected areas with tepid water, using either no soap or only a very mild soap (for sensitive skin). Areas were then to be patted dry gently and if possible exposed to air (by wearing loose-fitting or no underwear). Subsequent irritation was to be avoided by choosing the one topical remedy which proved to be the most effective and avoiding all other products for at least 7 days. Exposure to extreme temperatures and ultra-violet light was also discouraged. Patient Education In this case, the patient established a reputation as a very involved and pro-active member of her health management team. She was very open and enthusiastic about receiving education regarding recommendations in the management of both her VZV shingles as well as her CLL as a complicating factor. The relationship between her CLL and VZV disease was discussed and the patient understood that her lympho-proliferative disease (CLL) and chemotherapy treatments would continue to put her at higher risk for VZV reactivation in the future. The normal progression of VZV shingles from papules, to vesicles-bullae, to pustules and eventual crusts were discussed. Other aspects included in discussions during PC#1 encounter and/or subsequent follow-up visits and phone calls, included:Factors which may trigger reactivation of VZV (including: immunosuppression, certain medications, other infections, physical and emotional stress). Actions which can be taken to prevent reactivation (including: optimizing immune-status; infection control; avoiding, preventing or pro-actively managing stress)Early recognition of prodromal symptoms and timely initiation of anti-viral therapy at first signs of VZV skin rash (patient and providers agreed that patient is to maintain a home-supply of valacyclovir and although prophylactic continuation of the valacyclovir was not deemed appropriate at this time, she would initiate treatment at the earliest manifestation of VZV rash, or similar prodromal neuralgia).Pain control and management (especially how effective pain control could reduce the risk for PHN).Early recognition of serious complications such as (i) involvement of nasociliary branch of ophthalmic nerve with subsequent acute retinal necrosis, (ii) disseminated zoster (which may occur 5 – 10 days after onset of dermatomal disease), (iii) bacterial superinfections (especially skin infections), (iv) peripheral motor neuropathy, (v) meningitis/encephalitis, and (vi) Ramsay Hunt syndrome (herpes zoster oticus), and (vii) signs of visceral involvement (fever & lymphadenopathy). In this case, with know immune-compromise and the location of the patient’s skin rash (perineal area) special attention was given to discuss the prevention, early recognition and treatment of bacterial skin infection as a complication. It was decided that no prophylactic antibiotics (topical or systemic) were needed and she received praise for her existing vigilance in this area. Prevention/pro-active management of opioid-induced constipationPro-active management of long term implications involving physical functioning (fatigue, activity and rest, weight loss), psychological functioning (anxiety, depression), social functioning (changes in intimacy & social attendance) & functional areas (ability to continue/resume IADLs & ADLs). Regarding immunization against VZV shingles (recommended for people 60 years of age and older since 2006), it was discussed with the patient that despite the FDA’s 2011 approval for persons aged 50 to 59 years, the Advisory Committee in Immunization Practices declined recommendation of this vaccine for this age group (50-59 year olds). Additionally, despite the higher risk for immune-compromised patients to present with VZV reactivation, vaccine administration for its prevention is not advised in patients with primary or acquired immune-deficiencies (including leukemia, lymphoma or other malignancies of bone marrow or lymphatic system). For some patients, VZV vaccination is indicated prior to the start of immunosuppressive therapy, but since this patient is already challenged with immune-compromise, vaccination would not be indicated for her at this time. As already discussed under the treatment for Contact Dermatitis, the patient was cautioned against the use of too many topical remedies to avoid irritation of or further damage to the skin. Follow-up The plan for follow-up included the following:Re-visit the primary care provider in no more than 4 weeks for routine follow-up. Return at an earlier stage would be indicated if:Any signs or symptoms of complications (as discussed under Patient Education paragraphs e – g) manifest.Any new lesions occur (and patient understood that she could immediately start a second course of anti-viral therapy with home-supply of Valacyclovir).Any increase in pain (especially visceral pain), or constitutional symptoms (such as fever, malaise, petechiae or lymphadenopathy) manifest. Assessment at subsequent visits would specifically address skin integrity, pain control, resolution of skin rash, psychological wellness and restoration of optimal immune-status. Patient is also to maintain her follow-up schedule with her oncologist which, at the time of PC#1 was stipulated at quarterly visits with the oncology team and monthly CBC and basic panel labs checked at the primary care clinic and faxed to her oncologist. Specific to pain management it was decided that if patient’s pain is not significantly controlled in 14 days, the patient would return to the clinic for assessment and most likely started on Gabapentin for increased pain control. Referrals At the time of PC#1, no new referrals to specialty care were initiated but her plan of care and follow-up included referrals to:Pain management specialist – if treatment with opioid and adding Gabapentin failed to provide adequate pain relief OR if pain would become severe or refractory to treatment at any time. Opthalmology – if any ophthalmic nerve involvement manifested or were suspectedHospitalization – if any signs of disseminated herpes would appearOncology – to maintain her current follow-up schedule (quarterly visits)Patient and family involvement in treatment decisions The patient maintained absolute involvement in her treatment decisions. As already mentioned she had a very pro-active attitude and spent many hours researching conventional and less conventional treatment options using different sources. In general she was able to make sound, informed decisions and where needed, received guidance from her primary health care team (example: not to overuse topical remedies) and from her specialty care provider (oncology) regarding the preference of Valacyclovir (above Famciclovir) in this case. Although the patient’s husband always accompanied her to the clinic, he opted not to be present in the examination room but accepted the invitation to ask questions in a way and at a time suitable for him. The patient reported that he did take an active interest in her condition but that he preferred discussing it with her. She also shared findings and treatment decisions with her daughter (according to the patient) who supported her in her treatment decisions and usually accompanied the patient and her husband to oncology visits. The patient introduced the primary care provider and FNP student to the concept of EFT (Emotional Freedom Techniques). In this self-taught treatment, the patient was able to combine principles of bio-feedback, acupuncture, acupressure and thought field therapy into a meditative session while tapping on so-called "end points of the body's energy meridians". She found this to be very helpful in pain relief but also to replenish her emotional energy. As this appeared to be beneficial to the patient, she was encouraged to continue with this type of therapy. Reflection on Care Provided Care provided by the FNP student included a single primary care visit (PC#1) at which time an acute concern which manifested 10 days prior was being re-addressed. The visit was prompted by the concern of either disease regression or a second exacerbation of the same symptoms. Inadequate pain management and the development of complications were also a concern. The PC#1 encounter afforded time for a thorough review of symptoms, physical exam, review of past medical history and family as well as social history. Due to the remote geographical location of the clinic, the patient was co-managed by a physician assistant whom conducted the follow-up visit. In order to overcome this challenge, the FNP student was able to meet with the patient for a follow-up discussion and to discuss additional patient education topics. Additionally, the preceptor also followed the patient’s progress (as collaborating physician to the PA) and engaged in several discussions of this case with the FNP student. Reflecting on the lessons learned it really struck me how disease conditions which may not receive high-profile attention, may still manifest as complex conditions with profound implications for my patients. Diseases which may, by some, are described as simple and easy to manage, may in fact, produce serious health detriments when combined with the unique, individual features of our patients, which may truly determine the severity and impact of the disease in that individual case. Co-morbid conditions must always be considered and co-managed with integration of knowledge on how two distinctly separate pathological processes may intertwine. Further I’ve realized that the phenomenon of compromised immunity, either primary or acquired, can drastically change the face of many familiar diseases and challenge both patients and providers with unusual presentations, precocious manifestations, slower resolve and increased risk of complications (some of them equally unusual). Additionally, co-morbidities such as immune-compromise may limit our treatment options and methods of prevention and force us to think outside the box. The age of accessible information and technology offers our patients the opportunity to investigate their symptoms, often present us with a prepared list of differential diagnoses and challenge the treatment options we consider and recommend. This necessitates providers to constantly expand their knowledge and understanding of disease processes and treatment modalities and through the use of evidence based practice, recommend the most beneficial treatments to our patients. Finally, the biggest challenge lies in fusing clinical knowledge, social skills and due diligence into an individualized plan of care which would optimally benefit the patient as primary participant in his/her healthcare. ReferencesAlbrecht, M. A. (2011, February). Clinical manifestations of varicella-zoster virus infection: Herpes zoster. UpToDate. Retrieved from , M. A. (2011, October). Treatment of herpes zoster. UpToDate. Retrieved from , M. A. (2012, January). Prevention of varicella-zoster infection: Herpes zoster. UpToDate. Retrieved from , Z. H., Warfield, C. A., & Crovo, D. G. (2012, February). Postherpetic neuralgia. UpToDate. Retrieved from for Disease Control and Prevention. (2008, June 6). Prevention of herpes zoster: Recommendations of the Advisory Committee on Immunization Practices. Morbidity and Mortality Weekly Report, 57(RR-5). Retrieved from mmwrCenters for Disease Control and Prevention. (2011, November 11). 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Retrieved from , B. B., Lance, B. R., & Tomsik, E. A. (Eds.). (2010). Drug information handbook for advanced practice nursing (11th ed.). Hudson, OH: Lexicomp.Wolff, K., & Johnson, R. A. (2009). Fitzpatrick’s color atlas & synopsis of clinical dermatology (6th ed.). New York, NY: McGraw-Hill Medical.Appendix AFigure1: Genogram*** Please see separate word document for Genogram ***Appendix BTable 1: List of current medicationsDrugDosageIndications/DirectionsHydrocodone/Acetaminophen5mg/325mg tablets1 -2 tablets every 4 – 6 hours po prn for painDocusate Sodium100mg Gelcaps1 – 2 gelcaps at bedtime po prn for constipation (prevention) Vitamin D3 (Cholecalciferol)5,000 unit gelcaps1 gelcap daily poValacyclovir500mg tablets2 tablets, 3 times/day po for 7 days starting at first manifestation of herpetic rashProchlorperazine maleate10mg tablets1 tablet po every 6 hours as needed for nauseaDesitin Cream (40% zinc oxide)creamApply to affected skin areas after gentle washing as needed for relief of discomfort. Table 2: Laboratory report of hematology on PC#1 encounterCBC with Manual DifferentialTestResultFlagRangeUnitsWBC*3.8L4.5 – 10.5/mm3RBC3.983.69 – 5.13/mm3Hemoglobin14.011.7 – 14.5g/dLHematocrit38.934.1 – 44.3 %MCV*97.8H80.6 – 95.8U3MCH*35.1H27.1 – 33.1pgMCHC35.932.2 – 36.7%RDW12.110.3 – 12.9%Platelets152143 – 314/mm3MPV*5.5L6.0 – 9.0U3Lymph: % #29.7*1.1L19.4 – 42.91.2 – 3.0%/mm3Gran: % #54.22.039.3 – 73.71.2 – 7.0%/mm3Mono: % #10.90.44.4 – 12.70.2 – 0.8%Eos: % #1.60.10.6 – 7.30.0 – 0.4%Baso: % #*3.6*0.1HH– 1.70.0 – 0.1%ReflexYES204.10Manual DifferentialSEG manual6040-70%Lymph manual3220-45%Mono manual82-10%ANISO1+MACRO1+POIK1+Appendix C: Treatment Modalities/ConsiderationsTable 1: Anti-viral agents considered to decrease length and severity of acute episodeAgent:AcyclovirFamicyclovirValacyclovirFoscarnetDose:800mg po4 hourly (mostly given 5 x/day)7-10 days500mg po8 hourly7 days1,000mg po8 hourly7 days40mg/kg IV8 hourly over 1 hour infusion10 daysNotes: Primary drugInconvenience of frequent dosing requirement (5-6x/day)Pro-drugConsidered more helpful (than acyclovir) in prevention of PHNConvenient dosingPro-drugContra-indicated for some immune-compromised patientsConvenient dosingPro-drugOnly available for IV administration Reserved for cases resistant to acyclovirTable 2: Treatment options for PHN – Oral administrationPharmacological categoryTricyclicAntidepressantsAnti-convulsants (with analgesic properties)DrugNortriptylineGabapentin(Neurontin)Pregabalin(Lyrica)Carbamazepine(Tegretol)DoseStart:(Maximum)10-20mg QD100mg TID po (600mg TID)75mg QHS(300mg BID)100mg BID(600mg BID)Reason why consideredLimited support for use in conjunction with anti-virals during acute phase to prevent PHNAnti-neuralgic actionHighly recommended for treatment of PHNAnti-neuralgic actionHighly recommended for treatment of PHNAnti-neuralgic actionOften used for treatment of PHN & Trigeminal neuralgia Warnings / Reason(s) why not selectedIncreased risk for eosinophilia, purpura and thrombocytopeniaMay also aggravate peripheral neuropathyMay increase risk for leucopeniaMay take 2 -3 weeks to achieve optimal effectiveness. May increase risk for thrombocytopeniaContra-indicated for patients with bone marrow suppression.Warning: hypersensitivity may mimic signs & symptoms of lymphomaOther considerationsInteracts with many other drugsGeneric availableVery few drug-drug interactionsNo generic availableExpensiveInteracts with many other drugsFinal decision for this patientNot selected based on limited support and side-effect profileMost favored option – fewest interactions & EBP supportedNot selected - too expensiveNot selected based on side-effect profileTable 3: Topical preparations / options for treatment of PHNTreatmentLidocaine 5%Topical AspirinTopical Capsaicin 0.075% creamHow used / appliedPatch applied to intact skin after resolution of blisters and crustsAspirin tablets crushed & mixed into Vaseline / Eucerin creamApplied to intact skin after crusted lesions are healedReason why consideredMay be useful on buttock once all lesions are completely healed. Used in many compounded topical treatments Not consideredWarnings / Reason(s) why not selectedPatient still has blisters & crusted lesions. Patch not recommended for application on perineum/groin areaNot considered for use in perineal / groin areaFinal decision for this patientMay be useful at later time (after lesions are healed – use on buttock only)Used with success & will continue to useNot considered at allTable 4: Symptomatic measures utilized by the patientMeasures utilized with success(Is going to continue with these)Unsuccessful measures (ineffective/aggravating)(Tried but discontinued)Desitin ointment (with 4% zinc oxide)Applying heat to area / taking warm bath/showerCold, moist compresses (chilled, moist washcloths)Aloe Vera Gel, Calamine lotionIce packsBalmex ointment (with 11% zinc oxide)Cornstarch powderGold Bond powderLimiting mechanical irritation from clothes(wears loose-fitting clothes as tolerated)Benadryl cream, Aspercreme, Cortaid lotion, Vitamin E oilAspirin tablets crushed & mixed into Vaseline/EucerinApplying sun lamp (ultra-violet light) for 5 minutes per day (aggravated symptoms)EFT (Emotionally Focused Therapy)Dimethyl sulfoxide (DMSO) 50% cream ................
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