Hypothetical Patient Management

NON-TRAUMATIC PAIN TO SKIN AND SOFT TISSUE

BY: EDEN AURORA B. OPAY

TRIGGER 1
      
	Patient with complain of non-traumatic pain in skin and soft tissue

Questions:
 1. What is “non-traumatic pain in skin and soft tissue”?
            - any physical distress or suffering to the skin not caused by abrasion, bites, 	burns, laceration, puncture and surgical incision or venous access services             	- a disturbances in the skin and soft tissue secondary to infection

2. Possible causes
           > Bacterial infection
           > Fungal infection			   
           > Viral infection

		
             Organ/tissues involved    General condition/disorder   Specific cndition/dis.
	
        	  Epidermis/dermis              Bacterial infection	   Ecthyma				   			        Bacterial infection              SSSS
				        Viral infection		   Herpes simplex
 	  
	  Dermis/subcutaneous        Bacterial infection              Cellulitis and erysipelas
               
	  Hair follicles	 	        Bacterial infection   	  Abscess, Furuncle and 									  Carbuncle				 
              Dermatomes		       Viral infection		  Herpes Zoster	 		  Dermatomes/skin             Viral infection	              Herpes Simplex       
              Scalp			       Fungal infection		  Tinea Capitis
	  Beard and Moustache      Fungal infection             	  Tinea Barbae
             Feet 			      Fungal infection           	  Tinea Pedis
	 Hands			      Fungal infection		  Tinea Manuum	

3. What do you think are the more common/least common general and specific condition      	causing the health problem?

    			 General condition/disorder           Specific condition/disease
 
        More common       Viral Infection		        Herpes Simplex
	  						        Herpes Zoster	
    
       Least common        Fungal Infection		        Tinea Manuum

4. Select one common general or specific condition and diagrm the pathophysiology 		leading to the health  problem	

				HERPES ZOSTER

      		Varicella-Zoster Virus	         humoral and cellular immunity to VZV	
	     [during the course of varicella]                     
              		
•				passes                    			     with advancing age

	            from skin lesion                                            diminished the immunity toVZV

		sensory ganglia                                             viral replication

			established

		latent infection

			  reactivation

		virus travels to sensory nerve

		dermatomal pain followed by painful skin lesion 		

TRIGGER  2

      A 55 year-old male with severe pain of the skin in the chest noted 3 days ago with fever and body malaise.

Physical examination:	
         Erythematous maculopapular rash in the trunk
         Swollen and tender regional lymph nodes

Questions:	 

1.What is your primary and secondary diagnosis?
	Primary diagnosis: Herpes zoster
	Secondary diagnosis: Herpes simplex

2. What are the basis for your primary  and secondary  diagnosis?
             
	PRIMARY DIAGNOSIS: Herpes zoster
	Signs and Symptoms: severe pain, fever and malaise 
	Pathophysiology: During the course of varicella, HZV passes from the skin     				      lesionsto the sensory nerve then to the sensory ganglia and         				      establishes latent infection, virus then travels down the sensory 				      nerve resulting in the initial dermatomal pain followed by 				      painful skin lesion	
    	Prevalence data: HZV affects 66% over 50 years of age	

              SECONDARY DIAGNOSIS: Herpes simplex	
	Signs and Symptoms: severe pain, fever and malaise
	Pathophysiology: Close contact with infected person shedding virus at a peripheral
                                         sites, mucosal surface or secretion. Virus replication in parabasal                     			     intermediate epithelial cell causing lysis of infected cell	     				     vesicle formation and local inflamation, subsequent to infection 				     at inoculation site, HSV enter trigeminal or sacral or vagal root 				     ganglia where latency is established.Recurences result from viral 			     reactivation, synthesis and migration of virus through the sensory 			     nerves.
	Prevalence: HSV affects most commonly young adults

3. Do you need more data [signs/symptoms] to firm up your primary and secondary   	
	     diagnosis?
       	Yes for my secondary diagnosis
	Is there  focal neurologic symptom like dimentia which is the hallmark of HSV 	  	     encephalitis?

4. Do you need a paraclinical diagnostic procedure?
	Yes to identify the specific virus and to be certain with my primary diagnosis 

5. If you need a paraclinical diagnostic procedure, what will you recommend? Why?
	Give atleast 3 options and then compare using benefit, risk cost and availability   	factors then select one demonstrating priority on the primary diagnosis.

	Options	Benefit	Risk		Cost		Availability

Tzank Smear		B		R		C		A
Culture			BBB		R		CC		A
Antigen
    Detection
        Test		BBB		RR		CCC		A
 
CULTURE

6. Suppose the patient agreed to your recommendation of the paraclinical diagnostic  		           procedure and suppose it was done.
	What results will firm up your primary diagnosis?
	What results will make you shift to your secondary diagnosis as the primary  		          diagnosis?

            Isolation of Varicella-Zoster Virus - Primary dignosis
	Isolation of Herpes Simplex Virus - Secondary diagnosis

TRIGGER 3

	A culture was done

Questions: 	   
 
1.Examine the result of the paraclinical diagnostic procedure and then interpret.
	Decide whether the result is informative or non-informative.
	Informative, why?                         Non-informative, why?
     
	YES because a specific virus has been identified

2.  After  the paraclinical diagnostic procedure, what is now your primary and secondary  	diagnosis? Why?

	Primary diagnosis : Herpes Zoster
	Pattern recognition : Prodromal Stage  -  severe pain ( stabing, pricking, sharp, 	
							penetrating, lancenating, shooting)  
					                -  tenderness
					                -  paresthesia  ( itching, tingling, burning)
		                   Active Vesiculation  -  the lesion consist of grouped, tense, 								deep seated vesicle distributed 	
	Prevalence:  affect in 66% of >50 years old	unilaterally along the neural pathway 								of the trunk or face. 	
	Pathophysiology:    reactivation of VZV due to diminishing immunity of VZV
	Diagnostic procedure:  isolation of VZV

	Secondary diagnosis:  Herpes Simplex
	Pattern recognition:  Prodromal stage  -  paresthesia and severe pain along the 							    course of the nerve that may precede  or 							    acompany attacks 	
		        		Active vesiculation  -  the lesion consist of small, grouped 								vesicles  that can occur anywhere but 							more common in the vermilion border 							of the lips, labia and  perianal skin								
	Pathophysiology:  Reactivation of HSV due to exposure to stress related factors
	Prevalence:  affect most commonly young adults
	Diagnostic procedure:  isolation of HSV Type I

3.  Do you need to firm up your diagnosis before you proceed to treatment?  if yes, how?
     
     History		-          previous infection with varicella or HSV pharyngitis and 					 gingivostomatis				
                                    -          close contact with infected person
                                    -          living in crowded condition 
                                    -          lower socio-economic status
                                    -         on going or previous chemotherapy or radiotherapy
                                    -         HIV infected
                                    -         excessive sun exposure

    P.E.                         -         distribution of lesions - unilateral and or dermatomal
                                    -         sensory defects - temperature, pain, touch
   
Other diagnostic procedures -Tzanck  Smear   - giant  acantholytic keratinocytes or                                  						         multinucleated giant keratinocytes for 						         HSV 

 						       -  giant multinucleated cells for VZV
 				- Antigen Detection  -  monoclonal antibodies specific for 							            HSV - I
                                     			            -  VZV antigen
Observation and Monitoring   -  VZV  -  severe pain usually precede lesion by 48-72 						       hrs, and erythematous maculopapular rash 						       evolves rapidly into vesicular lesion.  In 						       normal host, this lesions may remain few in 						       numbers and continue to form only for a 						       period of 3-5 days.  Total duration of the 						       disease is generally 7-10 days , however it 						       may take as long as 2-4 weeks for    skin to 						       return to normal.

4.  What is your pretreatment primary and secondary diagnosis?
 	 Primary diagnosis:  application of moist dressing to the involved dermatome to 				         	soothe and alleviate pain
     	 Secondary diagnosis:  temporary isolation of the patient to prevent spread of 					infection

5.  State the goals of treatment for your primary diagnosis.
     *    Minimize pain
     *    Reduce viral shedding
     *    Speed crusting of lesions and healing
     *    Ease physical, psychological and emotional discomfort
     *    Prevent viral dissemination or other complication			
     *    Prevent or minimized postherpetic neuralgia “PHN”

6. Decide on the treatment modality after comparing the options based on benefit, risk, cost and availability factors.

				Benefit	Risk		Cost		Availability
Option 1             						 			
Non-operative			  BBB		R		CC		AAA	
Operative                                  not applicable

7.  Describe the things need to be done during the pretreatment, intratreatment and    posttreatment phase. 
Pretreatment  -  inform the patient that his VZV virus which he acquired early in life      		    have  been reactivated
	            -  inform the patient that lesion continue to form only for a period of 3- 			    5 days and the total duration of the disease may take as long as 2-4 			   weeks.
 	            -  a postherpetic neuralgia may develop but last for months to years

Intratreatment  -  Prodromal Stage  -  Antiviral agents  if diagnosis is considered 							likely
				       	 -  Analgesics
	           	-  Active Vesiculation  -  Antiviral agent should begin  more or less 72 						      hrs.   after lesion occurs	    
    					  -  continue dressing the lesion
					  -  narcotic analgesic for pain management

Posttreatment  -  Patient advice to go back to the clinic after 7 days of taking the 				   medication.

8.  Decide how you would evaluate the results or outcome of your proposed treatment.
     Follow-up check-up if :  healing of skin lesion have accelerated
			         decreased the duration of acute pain 	
			         decreased the frequency of PHN
			         dressing soothe and alleviates pain

TRIGGER 4 			The diagnosis of Non-traumatic pain of Skin and Soft 					Tissue is Herpes Zoster

Questions:
 
1.  Advice the patient and relatives of the pathophysiology of the disease.  Use diagram.

2.  Advice the patient and relatives on screening of the disease.
     *  Antigen Detection Test
     *  Examination  of  high risk individuals

3.  Advice the patient and relatives on early detection of the disease.
     *  Presence of severe pain along the thoracic and lumbar area strongly  suggest       	Herpes Zoster especially in individuals ages > 50 y.o.