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Case Study-Herpes Zoster

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Case Study on Herpes Zoster

Case Study on Herpes Zoster
History of Present Illness: This is a case of a 27 year old Asian female who came to the clinic complaining of pain on her right hand. She states that it feels like “pins and needles going up to my arm” She denies fever but states that she feels body malaise. She claims to have slight loss of appetite because of the pain. Pain level is about 7-8/10, occurs continuously and is temporarily relieved by Tylenol 500 mg. She noted the appearance of tiny blisters on her hand and upper arm which started about a week ago. The pain according to the patient is described as throbbing and tingling sensation. Patient otherwise has no other complaints.
Past Medical History: Patient denies prior hospitalizations, surgeries, accidents. Patient does not remember immunizations but she claims that she never had chickenpox
Family History: Both parents are alive. Her father is hypertensive and has coronary arterial disease. Her mother is apparently healthy. She is the only child.
Social History: She lives in an apartment with her parents. She works as an employee in the casino. She does not smoke and does not drink alcoholic beverages.
Review of Systems:
General: Well nourished female, not in acute respiratory distress
HEENT: Denies headache. No blurring of vision, hearing not impaired, no sore throat
Neck: No tenderness and lymphadenopathy
Cardiovascular: No chest pains and palpitations
Gastrointestinal: No change in bowel habits, slight loss of appetite
Genitourinary: No change in urinary habit
Musculoskeletal: Pain on right hand extending to right upper arm, feeling of “pins and needles” on right arm and hand, no limitation of movement both upper extremities, normal gait and posture
Neurologic/Psychiatric: Alert and oriented as to time, place and person
Physical Examination: Patient is a well nourished Asian female, ambulatory, in no acute respiratory distress
Vital Signs: BP 120/80 mmhg, Temp 97.6 F, RR 18/min, PR 85/min
Skin: Tiny blisters on dorsal aspect of right hand and lateral aspect of upper right arm, skin is warm and with good turgor, no other rashes on body
HEENT: Pupils equal in size and reactive to light and accommodation, extraocular muscles intact, otoscopic exam revealed normal auditory canal and eardrum, nares patent, oropharynx clear
Respiratory: Symmetrical chest, no abnormalities on palpation, resonant sounds on percussion, clear breath sounds, no rales or rhonchi
Cardiovascular: Normal on palpation of PMI, Regular rate and rhythm, no murmurs, no gallops
Abdomen: No lesions, tympanitic, normoactive bowel sounds
Musculoskeletal: No swelling of joints of upper and lower extremities, ROM of both extremities are normal
Assessment: Based on the classic lesion and presenting symptoms of the patient , she has a diagnosis of Shingles or Herpes Zoster and Pain related to nerve root inflammation and skin lesions Although herpes zoster typically resolves within 2 weeks, there may be ceratin complications that will pose health risks like secondary bacterial infection, motor involvement including weakness in “motor herpes zoster”, eye involvement with trigeminal nerve involvement which should be treated aggressively as this may lead to blindness. Another health risk is the development of postherpetic neuralgia which is a condition of chronic pain following herpes zoster. A variety of other conditions can cause a rash that may be confused with shingles, as prioritized, Herpes Simplex Virus (HSV) infection, contact dermatitis (especially toxic dermatitis from plant exposure, such as poison ivy), insect bite reaction, localized bacterial or viral skin infections which may all mimic symptoms of herpes zoster or shingles
Plan: Appropriate diagnostic studies: If the rash has appeared, identifying this disease and making a differential diagnosis requires only a visual examination, since very few diseases produce a rash in a dermatomal pattern. However, herpes simples virus (HSV) can occasionally produce a rash in such a pattern. The Tsanck smear is helpful for diagnosing acute infection with a herpes virus, but does not distinguish between HSV and VZV. Laboratory tests are available to diagnose herpes zoster. The most popular test detects VZV-specific IgM antibody in blood; this appears only during chickenpox or herpes zoster and not while the virus is dormant. In larger laboratories, lymph collected from a blister is tested by polymerase chain reaction for VZV DNA, or examined with an electron microscope for virus particles.
Therapeutic treatment Plan: The aims of treatment are to limit the severity and duration of pain, shorten the duration of a shingles episode, and reduce complications. For pain, this patient will be prescribed an over the counter analgesic such as Tylenol 500 mg 1 tablet PO every 4 hrs PRN for pain. Topical lotions containing calamine can be used on the rash or blisters and may be soothing. Once the lesions have crusted over, capsaicin cream (Zostrix) can be used. Bathe with cool water and wash the blisters twice a day with regular soap and water but do not bandage them .Apply cool compresses to the blisters to relieve the pain and itch.
Health Promotion and Education: and Prevention: All patients with herpes zoster should be educated on the disease process and natural course of the disease. The nursing /medical goal is to prevent infection and complications of the disease and to reduce the pain of shingles. Patients should be instructed on medications including dose, route, and side effects and when to report to PCP for redness, swelling, or drainage of the rash to PCP. Prevention of shingles include the chickenpox vaccine and avoidance of contact with infected persons. Although the chickenpox vaccine does not guarantee complete protection against chickenpox or shingles, it can reduce the severity of the disease and the risk of complications. High risk groups such as the Elderly, those with HIV, on steroids and pregnant women should avoid contact with infected persons
Follow-up: This patient is advised to take all medications as prescribed. If new symptoms or if the patient cannot control the pain or itching, she should contact her PCP immediately.

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