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Subjective. A 49 yo F presented to the office with a history of a red, patchy rash located on her left chest and extending to the middle of her back. The rash began one week prior. Pt complained of severe constant pain (9/10) along rash site, causing much discomfort and inability to lie on left side, leading to problems with sleep. Pt denies itchiness or tingling. Pt has history of sacroiliitis, osteoarthritis of lumbar spine, and posterior bulging of L2-L4 intervertebral discs..
49 year old woman with a red, patchy rash

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1. 49 year old woman with a red, patchy rash Outpatient Case Presentation Family Medicine Rotation Imtiaz Ather, OMS-III July 19th, 2007

2. Subjective A 49 yo F presented to the office with a history of a red, patchy rash located on her left chest and extending to the middle of her back. The rash began one week prior. Pt complained of severe constant pain (9/10) along rash site, causing much discomfort and inability to lie on left side, leading to problems with sleep. Pt denies itchiness or tingling. Pt has history of sacroiliitis, osteoarthritis of lumbar spine, and posterior bulging of L2-L4 intervertebral discs.

3. PMSX Chicken pox at age 5 Pt denies past surgical history or hospitalizations NKA Immunizations up to date Medications: 6/30/07: Prednisone 10 mg po: tid x 3days prescribed for exacerbation of sacroiliitis.

4. Social History Pt works as an office secretary, and admits that work has been stressful recently Pt is married with 2 children No recent travel outside US, no tobacco, alcohol, or recreational drug use. Pt eats 3 balanced meals daily, but does not exercise due to low back pain. Pt is unable to get adequate sleep due to low back pain and stress from work.

5. Family History Mother: deceased, had type II DM Father: deceased, had epilepsy 3 brothers and 3 sisters, alive and well 2 daughters, alive and well

6. ROS General: (+) fatigue, (+) loss of appetite Skin: (+) painful rashes along left side H: (-) headache, (-) dizziness, (-) rashes E: (-) changes in vision, (-) dry eyes E: (-) tinnitus, (-) pain, (-) vertigo N: (-) bleeding, (-) rashes, (-) itching T: (-) sore throat, (-) gum bleeding

7. ROS (cont?d) Breast: Pt does self-breast exams. (-) lumps, (-) pain Resp: (-) SOB, (-) cough, (-) wheezing Cardiac: (-) chest pain, (-) palpitations, (-) htn GI: (-) abdominal pain, (-) changes in bowel movements, (-) hemorrhoids Urinary: (-) dysuria, (-) hematuria Gynecological: Pt receives yearly exams. Gr2, para2. LMP: 6/2007 Musculoskeletal: (-) swelling, (-) weakness Neuro: (-) memory loss, (-) gait changes Endo: (-) polydipsia, (-) polyphagia, (-) ? sweating Extremities: (-) numbness, (-) bruising

8. Objective Well-nourished, well-groomed female patient, AOx3, in mild discomfort, leaning onto right side Vital signs: Temp: 97.6 P: 70 BP: 120/70 Resp: 16

9. Objective (con?t.) Skin: Erythematous, patchy, uniformly-sized macules located anteriorly at the left 6th sternocostal joint and extending posteriorly to the T6 spinous process, along the left T6 dermatome. Unilateral (does not cross midline) (+) tenderness upon palpation (-) vesicles, (-) blisters, (-) bleeding (-) pus (-) lymphadenopathy

10. Objective (con?t.) HEENT: (-) Lesions on face, lips, or oral mucous membranes. PERRLA. (-) conjunctivitis, (-) eyelid swelling (-) vesicles on nose, (-) lymphadenopathy Neck supple, FROM, (-) carotid bruits, (-) JVD. Chest: Normal AP diameter. CTA. See skin for info on lesions. Cardiac: RRR. S1 and S2 of normal intensity. Abdomen: Normal BS, (-) organomegaly, (-) bruits. Extremities: Pulses +2. FROM. (-) swelling. Osteopathic: ? AROM of lower back due to pain. Neuro: CN II-XII intact, (-) deficits, reflexes (+)2, Strength 5/5

11. Assessment Middle age woman with sudden onset of painful, bullous dermatitis. Differential diagnosis: Autoimmune bullous disorder Contact dermatitis Disseminated Coxsackie Virus Infection Impetigo Varicella zoster

12. Shingles Due to reactivation of Varicella Zoster Virus (aka Herpes Zoster)

13. Etiology Causes of VZV reactivation Pt must have hx of chickenpox infxn Greater risk if <2 months old when infected ?age (more common if over 50 yo) Immunocompromise (AIDS or immunnosuppresant therapy) Stress, trauma, bereavement Spinal cord surgery or spinal irradiation

14. Epidemiology Incidence: 200 per 100,000 ppl per year Freq: 10-20% of population at some point in life Not uncommon in immunocompromised pts (50% of Hodgkin?s lymphoma pts develop shingles) M=F

15. Common Symptoms Malaise, HA, Fever Acute, knife-like pain with tingling and itching, occurring 3-5 days before rash presents It can affect cranial nerves: facial nerve, peripheral hemiparesis of the face. acute loss of hearing, vertigo (Ramsay Hunt Syndrome).

16. Signs Closely grouped red papules, which rapidly become vesicular, appearing in a continuous band, generally in a single dermatome Occasional, some vesicles may be outside dermatome Usually u/l Lymphadenopathy of draining area

17. Acute

18. Signs (con?t.) Vesicle characteristics Become papular and/or hemorrhagic in 1-4 days Cloudy, with red base Varying sizes Become umbilicated briefly, then form crusts and fall off in ~3 weeks. May leave scarring.

19. 2 weeks

20. Diagnostic tests Usually based on clinical findings, but in case of doubt: Direct Antigen staining Tzanck test (shows multinucleated giant cells) Serology testing (shows ? VZV Ab) Viral culture from swab PCR (to detect VZV DNA)

21. Complications Disseminated VZV infxn Occurs in immunocompromised pts Severe skin eruption, with spread to organs causing pneumonitis, pancreatitis, encephalitis. Requires hospitalization, close monitoring.

22. Complications (con?t.) Herpes Zoster Ophthalmicus Reactivation at nasociliary branch of ophthalmic division of CN V Leads to involvement of cornea, iridocyclitis, and secondary glaucoma, which can lead to vision loss Vesicles will first be seen on tip and side of nose, with eyelid swelling and conjunctivitis Refer to dermatologist or ophthalmologist

23. Complications (con?t.) Postherpetic neuralgia Constant or intermittent intense stabbing pain along dermatome Worse at night or with temperature changes May last for months (rarely, years)

24. Treatment Begin herpes antiretroviral therapy w/in 72 hrs of onset of rash to speed resolution and ? risk of postherpetic neuralgia Acyclovir, Valacyclovir, or Famcyclovir 7-10 days, or until all lesions are crusted

25. Treatment (con?t.) For postherpetic neuralgia: Gabapentin (Neurontin) Similar structure to GABA, binds Ca channels, exact mechanism unknown Side fx: Dizziness, drowsiness, peripheral edema

26. Plan Pregabalin 75mg po bid x 30 days Course of acyclovir treatment Follow up in 1 week

27. References


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