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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
Immunizations up to date
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
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
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.
Autoimmune bullous disorder
Disseminated Coxsackie Virus Infection
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)
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
Lymphadenopathy of draining area
18. Signs (con?t.) Vesicle characteristics
Become papular and/or hemorrhagic in 1-4 days
Cloudy, with red base
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:
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