Which conditions should be considered as possible diagnosis? Any additional information that should be gathered to make the diagnosis?
Possible differential diagnosis I will consider are Herpes zoster, coxsackievirus infection varicella, poison ivy, herpes simplex virus, contact dermatitis, impetigo, and postherpetic neuralgia (Buttaro PhD AGPCNP-BC FAANP FNAP, Terry Mahan et al., 2016).
The clinical presentation of herpes zoster is vesicular eruption in a unilateral, dermatomal distribution (Buttaro PhD AGPCNP-BC FAANP FNAP, Terry Mahan et al., 2016, p. 998). Additional information that will determine the diagnosis are diagnostic tests such as culture vesicular lesions, Tzanck smear, I will also consider HIV test. Although, for Herpes zoster, diagnostics are not usually done.
Which condition is the women likely experiencing? Any other information that you should obtain from the patient?
This patient exhibits a classic sign and symptoms of herpes zoster, such as manifestation of a “very painful” vesicular, erythematous rash along her lateral rib area. The classical sign and symptoms of Herpes zoster is vesicles that run along a single dermatome, causing itching, burning, tingling, stabbing, or excruciating sensation at lesion sites (Buttaro PhD AGPCNP-BC FAANP FNAP, Terry Mahan et al., 2016, p. 997).
Subjective data that will gather from the patient will be to determine the onset, location, and progression of the rash. I will also ask the patient about prodromal symptoms such as itching, burning, tingling, or any painful sensation at the site before lesions broke out. Furthermore, I will also evaluate the patient status regarding any immunosuppressive agents such as prolonged use of high steroids, cancer treatment, radiation or chemotherapy, immunization history, medical history, allergies, and diseases. Because herpes zoster vaccine should not be provided to individuals who have lifelong threatening allergic reaction to gelatin or to individuals who have a weakened immune system (Buttaro PhD AGPCNP-BC FAANP FNAP, Terry Mahan et al., 2016, p. 478).
What treatment plan should you prescribe?
My initial treatment will include vital signs and a full head to toe physical examine, in which I will observe the skin for lesions, noting characteristics and distributions of the rash.
My general treatment and plan will be to provide comfort measures for the painful rash. I will instruct the patient to apply calamine lotions as needed, oatmeal (Aveeno) bath; Tylenol 325mg PO Q6 not to exceed 1000mg / day as needed for malaise, fever and discomfort (Cash & Glass, 2018).
Antiviral medication should be initiated within 24 to 48 after outbreak. Specially, Acyclovir (Zovirax) 800mg PO five times/ day x 7 days or Valacyclovir 1000mg (Valtrex) PO TID x 7 days for initial breakouts and 7 days for flareups (Saguil et al., 2017).
What follow-up care should you recommend?
Any herpes zoster lesions on the tip of the nose, around the eyas, and on the forehead requires immediate referral to an ophthalmologist, also treatment of complication may need a hospital evaluation (Buttaro PhD AGPCNP-BC FAANP FNAP, Terry Mahan et al., 2016). I will educate the patient to monitor for lesions around the eyes (along the dermatome distribution of the fifth cranial nerve, which can indicate herpes zoster ophthalmicus. This can lead to corneal blindness (Albrecht, 2022a).
Monitor for post-herpetic neuralgia, which can last for least a month after the rash is healed.
Recommend shingles/zoster vaccine for the patient and her children should catch up on their childhood immunizations. In addition, stress management education should be provided, since this is likely the rigger for patient’s shingles flare.
Based on the likely diagnosis, what are your concerns about the other members of the family?
Since the children are “not vaccinated against common childhood illness,” her children are at risk for developing chickenpox, as the rash is contagious to them (Albrecht, 2022b). Also, the patient should not breastfeed the baby since her vesicles are still fresh. It’s no longer contagious once the vesicles are crusted over. Furthermore, since her other children will likely get chickenpox, the and disease is airborne, they will not be able to go to school, preschool, or daycare.
References
Albrecht, M. A. (2022a). Treatment of herpes zoster in the immunocompetent host (M. S. Hirsch, Ed.). UpToDate. Retrieved February 6, 2022, from https://www.uptodate.com/contents/treatment-of-herpes-zoster-in-the-immunocompetent-host?search=herpes%20zoster&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Albrecht, M. A. (2022b). Vaccination for the prevention of chickenpox (primary varicella infection) (M. S. Hirsch & M. S. Edwards, Eds.). UpToDate. Retrieved February 6, 2022, from https://www.uptodate.com/contents/vaccination-for-the-prevention-of-chickenpox-primary-varicella-infection?search=chicken%20pox%20children&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3
Buttaro PhD AGPCNP-BC FAANP FNAP, Terry Mahan, JoAnn, T. A., Polgar-Bailey PsyD MPH FNP-BC CDE BC-ADM, Patricia, & Joanne, S.-C. A.-B. (2016). Primary care: A collaborative practice (5th ed.). Mosby.
Cash, J. C., & Glass, C. A. (2018). Family practice guidelines, fourth edition (book + free app) (4th ed.). Springer Publishing Company.
Saguil, A., Kane, S., Mercado, M., & Lauters, R. (2017). Herpes zoster and postherpetic neuralgia: prevention and management. American Family Physician, 96(10), 656–663. Retrieved February 6, 2022, from https://www.aafp.org/afp/2017/1115/p656.html