Case Presentation: Vesicular Rash

Group presentation on Herpes Zoster

1. Case presentation: Vesicular rash Athena Nathan, Constanza bridges, & Raela stander Texas tech health sciences center NURS5320 Summer 2014

2. Subjective: Patient Demographics Gender- Hispanic female Age- 71 year old Chief Complaint- : “The left side of my head hurts even more and now I have more blisters on my head and face” O nset- 2 days ago L ocation- Left side head/face D uration: Continuous for 2 days C haracter- Burning/itching A ggravating/Alleviating-No known aggravating or alleviating factors R adiation- Accompanied with headache T iming- Pain is constant with increasing severity S everity- Rates pain at 10/10. Interferes with sleep. P rior- Presented to clinic 2 days ago complaining of waking up with a headache and 2 blisters to the left side of forehead. (Microsoft, 2014)

3. Subjective: Review of systems Past Medical History ( PMHx ) Childhood illness: Chickenpox Past Surgical History Medications Allergies Health maintenance Immunizations Flu (2013) Social history Married and lives with husband of 54 years Retired secretary Cares for granddaughter intermittently Health habits Family History

4. Subjective: Review of systems + GENERAL: States headache/chills/difficulty sleeping and burning/itching to left side of head/face x2days. Denies night sweats or weight changes. + INTEGUMENTARY: Positive for rash to left-side of head. Denies bruising, changes in moles or pigment. + NEUROLOGIC: Headaches. Denies head trauma, loss of consciousness, dizziness, or problems with balance/coordination. EYES: Uses bifocal glasses for reading. Denies any blurry/double vision, vision changes, trauma, eye diseases. States last eye exam August 2013. ENT: Denies any hearing loss/changes, pain, tinnitus, recent infections. Denies epistaxis or difficulty swallowing. Denies nasal congestion or scratchy throat. Denies dentures, ulcers, or tooth problems. Last dental exam January 2014. CARDIOVASCULAR: Denies any night sweats, chest pain, edema, palpitations. RESPIRATORY: Denies any cough, hemoptysis, shortness-of-breath, dyspnea on exertion, exposure to TB. GASTROINTESTINAL: Denies incontinence, changes in bowel patterns, heartburn. No hematochezia , hematemesis. MUSCULOSKELETAL: Denies any pain, heat, swelling to joints. Denies problems with range of motion.   + MENTAL STATUS: Positive for increased stress related to caring for a young child. Denies any confusion, memory deficits, mood changes, thoughts of hurting self or others.

5. Objective: Physical exam + VITAL SIGNS: BP 117/84 P 79 regular R 20 regular T 101oral Ht : 5’0” Wt : 135 BMI: 26.4 GENERAL APPEARANCE: Ms. V is a pleasant, well-kept 71 year old Hispanic female who appears younger than her stated age and is alert, cooperative, and able to independently ambulate and move all extremities. She is a good historian with clear speech without evidence of cognitive impairment . + HEENT: No cephalic deformities. Various fluid-filled vesicles to left frontal/temporal/zygomatic area . PERRLA. Fundoscopic exam shows disc margins sharp without no cupping, hemorrhage, or exudate. Tympanic membranes intact and pearly gray bilaterally without erythema or effusion. Nares patent bilaterally without rhinorrhea or redness. Pharynx without exudate or pustules. Buccal mucosa moist, pink, without lesions. Gums pink without inflammation or bleeding. + SKIN: Rash as noted above. Intact, no other rashes, lesions, or bruises noted. Good turgor. No pallor, cyanosis, or jaundice noted. NEUROLOGIC : Alert and oriented to person/place/time. Appropriate mood and affect. CN II-XII grossly intact. Motor 5/5 bilateral upper/lower extremities. Deep tendon reflexes 2+. No tremors noted . RESPIRTORY: Breath sounds clear to all lung fields. No increased work of breathing. Chest wall expansion symmetrical. CARDIOVASCULAR: S1S2, regular rate and rhythm. No thrills, splitting, murmurs, gallops, or rubs. Pedal pulses 3+ bilaterally. No peripheral edema. GASTROINTESTINAL: Bowel sounds present x4. Soft, nontender , obese. No distension, masses, organomegaly , or aortic pulsation. No dullness to percussion. MUSCULOSKELETAL: Fully weight-bearing with full range of motion of all extremities. No erythema/pain/inflammation noted to joints.   (Microsoft, 2014)

6. Differential Diagnosis: thought process (Microsoft, 2014)

7. Differential Diagnosis: Contact dermatitis Thorough history to include any contact exposures to possible irritants. Notation of dermatitis pattern. (Weaver- Agostoni , 2014)

8. Differential Diagnosis: Contact dermatitis (Usatine , 2014)

9. Differential Diagnosis: Folliculitis Involves the hair follicle Most common areas for presentation include face, scalp, thighs, buttocks, axillae and inguinal areas. Presents as a pustule. Biopsy recommended when unclear of diagnosis or if empirical antibiotic therapy is ineffective (Ely, 2014)

10. Differential Diagnosis: Folliculitis (Usatine , 2014)

11. Differential Diagnosis: Herpes zoster (Hutchinson & Miller, 2014)

12. Differential Diagnosis: Herpes Zoster (Usatine , 2014)

13. Differential diagnosis Contact dermatitis possible, however given no changes in habits and no exposure to irritating contributors unlikely . Folliculitis possible, however given presentation and PMHx , not likely. Herpes zoster likely, PMHx of chickenpox, systemic response (febrile), dermatomal distribution of vesicular lesions, and does not cross midline of face. Presentation without thorough history of symptoms led patient to having diagnosis after second visit.

14. Differential diagnosis Herpes zoster: reactivation of varicella zoster Lifetime risk: 10-20% Risk factor: Age , immunocompromised, cancer Prevention: Zoster vaccination (average cost is $194.00). Level of evidence: A (SORT*). Presentation: Rash is vesicular and unilateral, dermatomal pattern. Level of evidence C (SORT*). Diagnosis: Diagnostic testing not recommended. Level of evidence: C (SORT*). (Hutchinson & Miller, 2014) *Strength of Recommendation Taxonomy

15. Available diagnostic testing

16. Available diagnostic testing Test Name Positive Likelihood Ratio Negative Likelihood Ratio Sensitivity Specificity Polymerase Chain Reaction (PCR) * 95.00 0.050 95% 99% Viral culture* 20.00 0.810 20% 99% Immunofluorescence* 3.40 0.240 82% 76% *Assumption that pretest probability is 50% (Bader, 2013; Hutchinson & Miller, 2014)

17. Available diagnostic testing Test Name Clinical Pathology* Any Lab Test Now* PCR $47 Not offered Viral culture Not offered Not offered Immunofluorescence $17 $39 Out of pocket expenses: FirstCare HMO Lab testing ordered during provider visit covered under copay Medicare part B Lab testing deemed medically necessary Approved provider *prescription required Any Lab Test Now Representative, personal communications, July 9th, 2014; Clinical Pathology Representative, personal communications, July 9th, 2014; FirstCare Representative, personal communications, July 9th, 2014.

18. Available Diagnostic testing No diagnostic testing recommended Test Name Negative Likely Positive ICD 9 code CPT code PCR < 499 DNA copies per mL n/a > 500- 2,000,000 DNA copies per mL 053.9 87799 Immunofluorescence < 0.9 ISR* 0.91-1.09 ISR* > 1.10 ISR* 053.9 86787 (Quest Diagnostics, 2014a; Quest Diagnostics 2014b)) Interpretation: *ISR = Immune Status Ratio

19. Treatment Antiviral : Initiation of treatment within 72 hours with antiviral is recommended in patients over 50. Level of evidence A (SORT). Pain control : Amitriptyline initiated within 48 hours reduces the incidence of postherpatic pain after 6 months in patients over 60. Acute pain can be managed with gabapentin, tramadol, NSAIDS, and tricyclic antidepressants. Level of evidence B (SORT). Corticosteroids have a modest benefit to acute treatment and are not routinely recommended. Level of evidence B (SORT). (Hutchinson & Miller, 2014)

20. Treatment Antiviral Dose How often Duration Costco pricing Acyclovir* 800mg 5 times/day 7 days $15.18 Valacyclovir 1000mg 3 times/day 7 days $30.77 Famciclovir 500-750mg 3 times/day 7 days $29.71 * On $4 prescription list at Wal-Mart Valacyclovir is superior to Acyclovir Famciclovir has similar results to Valacyclovir (Costco, 2014; Walmart, 2014)

21. Ethical Considerations United Nations Educational, Scientific and Cultural Organization (UNESCO) Human dignity Human rights Autonomy and individual responsibility Benefit and harm Respect for cultural diversity and pluralism Social responsibility and health ( Baumann, 2010; O’Mathuna , 2011 )

22. Ethical Considerations Patient- centered care Incorporating patient/family preferences in decision-making process Mrs. V is a private person and does not want her family at appointments Patient autonomy Keeping patient informed and respecting their health decisions Risk/benefit of antiviral treatment Dignity of the individual Respected decision to not involve family Discussed treatment options Supported her decision (Bell, 2014; CDC, 2012; Microsoft, 2014 )

23. Legal considerations APRN Scope of Practice Tasks that can be performed under a given licensure Outlines patient population, duties, and compensation Guidelines set by national professional organizations AANP Evaluates NP professional role, education, accountability, and responsibility Case Study Acted as primary care providers for a geriatric patient Diagnosing and overseeing new and existing medical conditions (AANP, 2013; Texas Board of Nursing, 2005)

24. Legal considerations APRN Standards of Care What another provider would do given the same circumstance Determination if patient received safe and effective care with best possible outcome Case Study Met through assessment, diagnosis, development, and implementation of the treatment plan. Gave detailed follow-up instructions to evaluate treatment plan Barriers to practice or patient care: none (AANP, 2013; Buppert , 2008; Office, 2014)

25. Questions??

26. References American Association of Nurse Practitioners. (2013a). Scope of practice for Nurse Practitioners . Retrieved from https://www.aanp.org/images/documents/publications/scopeofpractice.pdf American Association of Nurse Practitioners. (2013b). Standards of practice for Nurse Practitioners . Retrieved from https://www.aanp.org/images/documents/publications/standardsofpractice.pdf Any Lab Test Now Representative, personal communications, March 29 th , 2014 . Bader, M. S. (2013). Herpes zoster: Diagnostic, therapeutic, and preventive approaches. Postgraduate Medicine, 125(5), 78-91. doi:10.3810/pgm.2013.09.2703 Bell, L. (2014). Patient-centered care. American Journal of Clinical Care , 23 (4), 325. doi : 10.4037/ajcc2014383 Baumann, S.L. (2010). The limitations of evidence-based practice. Nursing Science Quarterly . 23(3), 226-230. doi : 10.1177/0894318410371833 Buppert , C. (2008). Nurse Practitioner's business practice and legal guide . (3rd ed.). Sudbury, Massachusetts: Jones and Bartlett. Centers for Disease Control and Prevention. (2012, September 01). Self-study modules on tuberculosis . Retrieved from http://www.cdc.gov/tb/education/ssmodules/module7/ss7reading2.htm Clinical Pathology Representative, personal communications, March 29 th , 2014 . Costco (2014). Pricing information. Costco Pharmacy. Retrieved from: http:// www2.costco.com/Pharmacy/druginformation.aspx?p=1&SearchTerm= Ely, J.W. (2014). Folliculitis. Essential Evidence . Retrieved from: http:// www.essentialevidenceplus.com.ezproxy.ttuhsc.edu/content/eee/733 Essential Evidence Plus (2013). Herpes zoster. EBM Guidelines. Retrieved from: http:// www.essentialevidenceplus.com.ezproxy.ttuhsc.edu/content/ebmg_ebm/17 FirstCare Representative, personal communications, March 29 th , 2014. Hutchinson, A. & Miller, M. (2014). Herpes zoster (shingles). Essential Evidence. [Algorithm: diagnostic approach]. Retrieved from: http://www.essentialevidenceplus.com.ezproxy.ttuhsc.edu/content/eee/313Bottom of Form

27. References Hutchinson, A. & Miller, M. (2014). Herpes zoster (shingles). Essential Evidence. [Table: diagnostic testing]. Retrieved from: http://www.essentialevidenceplus.com.ezproxy.ttuhsc.edu/content/eee/313Bottom of Form Microsoft (2014). Microsoft Clip Art. [Pictures] Retrieved from: www.office.com O'Mathuna , D. P. (2011). Ethical considerations for evidence implementation and evidence generation. In B. M. Melnyk & E. Fineout-Overholt (Eds.), Evidence-Based practice in nursing and healthcare: A guide to best practice (2nd ed., pp. 474-487). Philadelphia, PA: Lippencott Williams and Wilkens . Quest Diagnostics. (2014a). Varicella-Zoster virus antibodies. Retrieved from http://www.questdiagnostics.com/testcenter/BUOrderInfo.action?tc=34128&labCode=DAL Quest Diagnostics. (2014b). VZV,QN,PCR. Retrieved from http:// www.questdiagnostics.com/testcenter/BUOrderInfo.action?tc=19493X&labCode=QBA Texas Board of Nursing. (2005, October 10). Guidelines for determining APN scope of practice. Retrieved from http://www.bon.texas.gov/practice/apn-scopeofpractice.html United Nations Educational, Scientific and Cultural Organization. (2006). Universal declaration on bioethics and human rights . Retrieved from http://unesdoc.unesco.org/images/0014/001461/146180E.pdf Usatine, R. (2014). Herpes zoster (shingles). Derm Expert. [Pictures: facial presentation]. Retrieved from: http://www.essentialevidenceplus.com.ezproxy.ttuhsc.edu/tools/dermExpert/index.cfm Usatine, R. (2014). Contact dermatitis. Derm Expert. [Pictures: facial presentation]. Retrieved from: http://www.essentialevidenceplus.com.ezproxy.ttuhsc.edu/tools/dermExpert/index.cfm Usatine, R. (2014). Folliculitis. Derm Expert. [Pictures]. Retrieved from: http://www.essentialevidenceplus.com.ezproxy.ttuhsc.edu/tools/dermExpert/index.cfm Weaver- Agostoni , J.S. (2014). Contact dermatitis. Essential Evidence. Retrieved from: http://www.essentialevidenceplus.com.ezproxy.ttuhsc.edu/content/eee/726 Walmart (2014). Retail prescription program drug list. Retrieved from: http:// i.walmartimages.com/i/if/hmp/fusion/customer_list.pdf