Discussion #4: Describe your clinical experience for this week
Did you face any challenges, any success?
Skin disease is a common medical problem and represents 8.4% of all primary care cases (Rübsam et al., 2016). Dermatological conditions can be challenging for the novice provider due to a general lack of knowledge, training, or exposure to the wide range of conditions that affect all populations across the lifespan. My preceptor was instrumental in assuring me there are a plethora of reputable and accessible resources that we as providers can utilize to increase our knowledge and provide the best treatment for our patients. The American Association of Nurse Practitioners (AANP) and the Journal of the American Association of Nurse Practitioner (JAANP), offer varying identification tools and treatment algorithms for dermatological condition based on the most current, evidenced-based practice. UpToDate, an application I’ve found to be an invaluable resource, offers a comprehensive database to help assess, diagnose, and treat all diseases and symptoms and can be specified by population. Images of skin disorders is crucial for the novice provider for which I found dermt to be extremely useful. The success was being afforded the time to research and diagnose several conditions throughout my clinical experience including acne, atopic dermatitis, rosacea, psoriasis, and most recently, shingles.
Describe the assessment of a patient.
S.) CC: “I’ve had tingling pain on the right side of my cheek for several days and now I have this itching rash.”
HPI: J.B. is a 68-year-old, Caucasian female, who presented to the community health clinic with a chief complaint of pain along the right side of her face. The onset of pain began 5 days ago and is described as constant, relentless, tingling, burning, aching pain rated 9/10. She denies any alleviating (has tried applying an OTC topical 1% hydrocortisone cream and acetaminophen) or aggravating factors. This morning as the itching intensified, she noticed a rash (vesicular eruptions) appear on the right side of her face. She denies using any new lotions or soaps or exposure to any irritants. She denies having a fever but admits to feeling general malaise, interrupted sleep, decreased appetite, and mild anxiety since the pain began.
PMH: Her PMH is significant for diabetes myelitis type 2 (2015, currently well controlled) for which she takes Metformin and is compliant with her nutritional plan. FX: Mother alive with DM type 2, glaucoma, and hypertension. Father deceased (74) from CVD. Sister deceased (60) breast CA. SX: Pt denies smoking, using illicit drugs, drinking ETOH, or caffeine. She is retired (formerly a secretary at a school), and is married and lives with her husband, adult son (and his wife), and 2 grandsons. She denies intimate partner violence, feels safe at home, and attends church regularly as a practicing Catholic. She denies allergies to medications, latex, or environment. Her last physical exam was one year ago. She states she is current with vaccinations (Tdap, pneumococcal, and influenza (but has not received the Shingrix vaccine which was recommended at her previous well visits because she did not think it was necessary. She also reports not wanting to receive the Covid-19 vaccine at this time.
ROS: A detailed ROS followed for which the patient admitted to mild headache pain beginning 5 days ago, aching discomfort in her right eye without visual disturbance or photophobia, and numbness/tingling sensation in the corners of her right upper and lower lip. She denies fever or chills. Reports a generalized fatigue feeling similar to “flu-like” symptoms. GI: Pt denies nausea, vomiting, or diarrhea but reports a decreased appetite. She denies any change in her weight. Integument: Pt reports itching, tingling, aching, and burning pain on the right side of her face with a clear vesicle rash.
O.) Vital signs: BP 140/68 (left arm, sitting). Temp. 99.0 degrees F. (orally). HR. 90 apical. RR. 20 Pulse Ox 99%. Pain level 9/10. Ht. 5’6. Wt. 165 lbs. BMI: 27. General: Pt. is a 68-year-old, Caucasian female, AAOx3, well-groomed, well-nourished, anxious, and in apparent acute distress. A comprehensive, head-to-toe physical examination followed. The integument of her face was noted to have grouped vesicles on an erythematous base on her right jaw, cheek, and around her right eye and forehead. No vesicles were noted in her tympanic, nasal or oral cavities. Her right outer eye is notable for swelling and erythema.
A.) Diagnosis: Herpes Zoster (Shingles or reactivation of latent varicella-zoster virus type 3). According to Kennedy-Malone et al. (2019), diagnosis for herpes zoster is based on clinical appearance and distribution of the eruption and on careful history of when the rash appeared. Differential diagnosis as this patient is post eruption include contact allergic dermatitis and grouped vesicles related to a viral infection.
P.) While there are diagnostic tests such as the direct immunofluorescence with fluorescein-tagged antibody (DEA) or polymerase chain reaction (PCR), these tests can be expensive and delay treatment (Hollier, 2018). Additionally, given the severity of vesicles on her face, J.B. was sent directly to the ophthalmologist for immediate, further evaluation. Ocular complications occur in about one-half of patients with involvement of ophthalmic division of the trigeminal nerve and include keratitis, anterior uveitis, and cornea ulceration (Kennedy-Malone et al., 2019). A CBC, CMP, and hemoglobin A1c were drawn to asses for markers for infection, blood count, renal function and glycated hemoglobin levels given the patient’s history. Antiviral treatment was initiated along with analgesics for pain. Patient to return in one week for Ophthalmologist follow up, evaluation of vesicular lesions, and pain management evaluation. Patient instructed to initiate airborne and contact precautions at this time for those who are pregnant, immunocompromised, and less than one years old.
What did you learn from this week’s clinical experience that can beneficial for you as an advanced practice nurse?
As aforementioned, I’ve learned from this week’s clinical experience, varying tools which are available to guide the advanced practice nurse in diagnosis and treatment of dermatological conditions. These resources are also beneficial to the patient as many of them offer printable education pamphlets. The information within the brochures are important for patient adherence to treatment and the overall achievement of optimal health results.
References
Hollier, A. (2018). Clinical guidelines in primary care (3rd ed.). Advanced Practice Education Associates.
Kennedy-Malone, L., Lori Martin Plank, & Evelyn Groenke Duffy. (2019). Advanced practice nursing in the care of older adults (2nd ed.). F.A. Davis Company.
Rübsam, M. L., Esch, M., Baum, E., & Bösner, S. (2016). Diagnosing skin disease in primary care: a qualitative study of GPs’ approaches. Family practice, 32(5), 591–595. https://doi.org/10.1093/fampra/cmv056
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