Mr. Ochoa, a 65-year-old gentleman, completed a Health Service Request form for a complaint of upper chest pain that radiates to his side with a rash. It has been getting worse over the last 2 days. He reported that he had been using Ibuprofen from the commissary without effect.
Nursing Sick Call Evaluation
SUBJECTIVE
Mr. Ochoa was seen in Nursing Sick Call that evening day and reported that the pain was of a burning and sharp nature and had been getting worse over the last 2-3 days. It was worse when laying on his right side. He reported that he worked in the kitchen, and initially thought he had just “lifted something wrong,” but usually when this happens, he is better in a day or two. He states that he has never felt this type of pain before. He also said that this morning he noticed a rash on his stomach. It is itchy. He also complained that the pain is now worsened with “even breathing.”
Allergies: No known drug allergies; no known food allergies.
Medications:
- Metformin 1,000 mg PO BID.
- Sliding scale insulin PRN – has not had to use this during his incarceration.
- Atorvastatin 20 mg QD.
- Lisinopril 20 mg PO QD.
- Aspirin 81 mg PO QD.
OBJECTIVE
Vitals: T 37°C (98.6°F), P 88, R 14, BP 138/82, WT 188 lbs, HT 67 in., BMI 29, blood glucose 134.
General: Alert, oriented male. Grimacing and appears in pain with guarded movements. Psychiatric: Good historian with linear thought processes.
Skin, Hair, and Nails: Right sub-xiphoid area with 1- to 2 cm papular vesicular rash No other lesions or rashes noted. Hair and nails unremarkable.
Head: Normocephalic, atraumatic.
Eyes: PERRLA, EOMI. Pupils 3 mm bilaterally.
ENT/Mouth: Dentition in good repair. Gross hearing intact. Bilateral Tympanic Membranes pearly grey and unremarkable.
Neck: Full Range of Motion (FROM).
Chest: Symmetrical.
Lungs: Clear to auscultation bilaterally without adventitious sounds. Good air movement heard.
Heart: RRR, without murmur/gallop/rub.
Back: Right back tender to touch at approximately T7. No other abnormalities noted.
Abdomen: Obese. Moderate tenderness right upper quadrant and epigastric area to light touch; otherwise, non-tender to palpation. + Bowel sounds all four quadrants.
Neurologic: Cranial nerves II to XII intact. Normal gross motor sensation in upper and lower extremities.
CORRECTIONAL NURSE ACTIONS
Discussed with provider, who wanted to see Mr. Ochoa the next morning in clinic for diagnosis and intervention. Mr. Ochoa was moved to an isolation medical cell until seen by the provider.
Mr. Ochoa is then seen by the Provider the next morning
PROVIDER ACTIONS
Review of Systems
A ROS is positive for difficulty sleeping related to right upper abdominal pain, fatigue, mild dyspepsia, decreased appetite, and mild dyspnea on exertion related to pain. The ROS is negative for fever, chills, cough, vomiting, sick contacts, melena, hematochezia, liver disease, HIV, headache, dizziness, blurred vision, recent travel requiring prolonged sitting, paroxysmal nocturnal dyspnea, lower extremity, palpitations, paresthesia, or muscle weakness.
Relevant History
Mr. Ochoa’s medical history is significant for well-controlled type 2 diabetes, hypertension, hyperlipidemia, and obesity. His surgical history is significant for cholecystectomy at age 48. He reports usual childhood illnesses. Social history is significant for one to two beers per day in the free world. He has been incarcerated for 6 months. The patient quit smoking cigarettes at age 48 and denies recreational drug use. He is heterosexual with no history of sexually transmitted infections.
Provider Physical Examination
General: Alert, oriented male. Grimacing and appears in pain with guarded movements. Psychiatric: Good historian with linear thought processes.
Skin, Hair, and Nails: Right sub-xiphoid area with 1- to 2 cm papular vesicular rash on background of hyperemia in clusters, extending laterally to midclavicular line in dermatomal pattern. Few dispersed vesicles noted. No lymphadenopathy to axilla. No other lesions or rashes noted. Hair and nails unremarkable. Hair present to lower extremities and dorsum feet, with even distribution bilaterally.
Head: Normocephalic, atraumatic.
Eyes: PERRLA, EOMI. Pupils 3 mm bilaterally.
ENT/Mouth: Dentition in good repair. Gross hearing intact. Bilateral TMs patent.
Neck: Full Range of Motion (FROM), trachea midline, no adenopathy.
Chest: Symmetrical, no axillary adenopathy.
Lungs: Clear to auscultation bilaterally without adventitious sounds. Good air movement auscultated.
Heart: RRR, without murmur/gallop/rub.
Back: No spinous tenderness. Right back tender to touch at approximately T7; inferior angle of scapula level. FROM neck with flexion, extension, lateral and rotational movements. FROM left and right shoulder without scapular winging.
Abdomen: Obese. Moderate tenderness right upper quadrant and epigastric area to light touch; otherwise, non-tender to palpation. No peritoneal signs. No ascites. Murphy sign negative. Negative rebound.
Neurologic: Cranial nerves II to XII intact. Hyperesthesia right T7 to T8 dermatomes; otherwise normal gross motor sensation in upper and lower extremities.
Differential Diagnoses for Mr. Ochoa
Vertebral fracture or nerve impingement could be a consideration. Although some vertebral fractures may occur atraumatically, they are typically associated with spinal and/or paraspinous tenderness. The simultaneous presentation of painful rash makes this diagnosis unlikely.
Sweet syndrome can cause herpetiform lesions and can involve the truncal region. This is an unlikely diagnosis because the rash is typically non-dermatomal and associated with constitutional symptoms and signs of infection, leukocytosis, underlying malignancy, or drug-induced and related causes.
Herpes zoster (shingles) is a likely diagnosis for this patient. The presence of a vesicular rash, insidious onset, dermatomal distribution of the rash, and the patient’s age are consistent with uncomplicated herpes zoster.
Herpes simplex virus is an unlikely diagnosis given the location of the herpetiform blistering. Localized dermal eruption is typically not associated with the acute neuritis found with varicella zoster. Likewise, the condition is usually associated with malaise, flu-like symptoms, and lymphadenopathy and primarily affects the face or genitals.
Pulmonary embolism is an unlikely diagnosis for this patient. Thoracic pain on inspiration with new onset dyspnea on exertion can be associated with pulmonary embolism or pleurisy. This is unlikely in this patient because he is active and does not present with cough or symptoms of DVT. The index of suspicion for this comorbid condition remains low given the overall picture and simultaneous painful vesicular rash.
Occult malignancy should be considered because the patient has a history of tobacco use. Herpes zoster may be a secondary presentation associated to stress from bodily insult from a primary malignancy. This would be unlikely because the patient has had no weight loss and was well prior to this incident.
Most Likely Diagnosis: Herpes Zoster (Shingles)
A patient with painful dermatomal distribution of vesicular rash is suspicious for this diagnosis, especially in this age group. Clinical judgment is important to rule out other co-morbid conditions, including immunocompromised conditions that would require further testing.
Diagnostic Tests/Imaging
No other testing would be indicated for an otherwise healthy individual who presents with discrete evidence of a painful rash in a well-defined dermatomal pattern.
PATHOPHYSIOLOGY
Herpes Zoster
Herpes zoster, commonly known as shingles, is a latent response to the reactivation of the varicella zoster virus in the body. After initial or primary exposure to the virus, it can remain dormant in the dorsal root ganglia for decades. Latent reactivation of the virus is most often associated with lowered immunity and is common in individuals older than 60. The incubation period may be up to 21 days preceding the hallmark vesicular rash in a well-defined dermatomal distribution. It can involve visceral, cranial, or spinal nerves. While typically localized to one area, Zoster may be widespread in patients with severe immunosuppression (chemotherapy, AIDs, post organ transplant).
PLAN
Valacyclovir 1000 mg PO TID for 7 days.
Tylenol 500 mg ii tablets BID x 7 days [consider stronger pain medication if not controlled with the Tylenol]
Keep Mr. Ochoa in the medical unit with isolation precautions for a week 2/2 contagiousness of varicella and the need for more frequent medication administration.
Review the health records of other patients in unit/potentially exposed and evaluate anyone at risk
See patient during medical unit rounds; follow-up Provider Sick Call appointment in 2 weeks
PATIENT EDUCATION
Herpes zoster vaccine – to be considered only after resolution of this acute episode. For diabetic patients, the recombinant zoster vaccine is recommended. It is two injections, 2-6 months apart.
Importance of monitoring blood glucose BID
Short and long-term management of postherpetic neuralgia; potential for future exacerbations
Valacyclovir/Antiviral medications: risks and benefits
COMMENTS
Mr. Ochoa followed his treatment plan and had no adverse outcomes. The pain was controlled with the ordered Tylenol, and he returned to his housing unit after a week. At the two-week provider encounter, he had almost complete resolution of the lesions. He was scheduled for the herpes zoster vaccine at his next Chronic Care visit.
REFERENCES
CDC. Herpes zoster (shingles). https://www.cdc.gov/shingles/hcp/clinical-overview.html
Dworkin R, Johnson R, Breuer J, Gnann J, Levin MJ. Recommendations for the management of herpes zoster. Clin Infect Dis. January 1, 2007;44: S1–S26. doi:10.1086/510206
Johnson R, Alvarez-Pasquin MJ, Bijl M, Franco E, Jacques G. Herpes zoster epidemiology, management, and disease and economic burden in Europe: a multidisciplinary perspective. Ther Adv Vaccines. July 2015;3(4):109–120. doi:10.1177/2051013615599151
Nalamachu S, Morley-Forster P. Diagnosing and managing postherpetic neuralgia. US Nat Lib Med, Nat Inst Health. November 2012;29(11):863–869. doi:10.1007/s40266-012-0014-3
Oster G, Harding G, Dukes E, Edelsberg J, Cleary P. Pain, medication use, and health-related quality of life in older persons with postherpetic neuralgia: results from a population-based survey. J Pain. June 2005;6(6):356–363. doi:10.1016/j.jpain.2005.01.359
Weaver B. The burden of herpes zoster and postherpetic neuralgia in the United States. J Am Osteopath. March 2007;107:S2–S7.
Wijesinghe, Sampath. (2021). 101 Primary care case studies: A workbook for clinical and bedside skills. Springer Publishing Company. Kindle edition.
*As always, your company or facility policies, procedures and Nursing Protocols/Guidelines take precedence over any written recommendations on this website.
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