Make sure to respond to at least two of your fellow classmates postings as well and challenge each other to go beyond just the surface.
Share your thoughts on how you support or disagree with their diagnosis and explain why.
Present new references that support your opinions.
Please be sure to validate your opinions and ideas with citations and references in APA format.
PLEASE USE UPDATED REFERENCES FOR EACH PEER RESPONSE I WILL PROVIDE EACH POST TO RESPOND
PEER #1

Scenario: A 35-year-old woman presents to the walk-in clinic with an erythemic rash along her left lateral rib area, somewhat under her breast, which she
describes as “very painful.” You note it has a few vesicles developing. The woman has a 6-month-old infant who is breastfeeding and three other children
over 3 years of age, all of whom the parents have chosen not to vaccinate against common childhood illnesses. The woman describes recent stress related
to providing 24-hour care in her home to her mother, who is seriously ill. The woman is seeking treatment for the painful rash.
Which conditions should be included in your list of differentials?
Considering the given descriiption of this rash is erythemic, unilateral, very painful, and has vesicles it sounds like shingles (herpes zoster). However, some
differential diagnoses should include herpes simplex virus, cellulitis, impetigo, insect bites/stings, Coxsackie viral infections, candidiasis and perhaps even
adverse reactions to any medications/supplements (Macrae et al., 2019).
What additional information should be gathered to make the diagnosis?
Taking a thorough history before doing the physical exam would be important to gather needed information to make the proper diagnosis. As with all history
intake utilizing the acronym, OLDCARTS will be used: onset, location, duration, characteristics, aggravating factors, relieving factors, treatments, and
response to those treatments, as well as the severity (Dunphy et al., 2019). In addition to these questions being asked, because she has chosen to not have
her children get vaccinated I would want to know if she had been given the chickenpox vaccine or if she ever had the chickenpox before because herpes
zoster is an infection by the varicella-zoster virus which causes chickenpox (Smith, 2020). I would also want to know if any of her kids currently have
chickenpox if she has been around anyone with chickenpox or who has a rash similar to hers. Asking her if she has any fatigue, fever, or headache should be
done (Smith, 2020). I would also want to know if there is any fluid draining from the rash (Dunphy et al., 2019). Asking her if she has been outdoors, recently
camping or hiking, noticed any insect bite needs to be addressed. The scenario also states she is a mother of 4 and also taking care of her mother 24/7 so
this increased stress should be discussed to help make the proper diagnosis and treatment plan.
Which condition is the woman likely experiencing?
As mentioned in question 1, this patient is most likely experiencing herpes zoster, commonly known as shingles.
What treatment plan should you prescribe for the woman? Provide full prescriiption details.
Early intervention in the treatment of herpes zoster produces the best results, but we do not know the onset.
Valacyclovir 1000 mg po every 8 hours for 7 days can be prescribed as an antiviral to shorten the duration of viral shedding, stop the formation of new
lesions and reduce pain severity (Epocrates, 2021). Valacyclovir is also fine for breastfeeding mothers (Epocrates, 2021).
Prednisone may assist in reducing acute pain when given with antiviral therapy (Dunphy et al. 2019). Prednisone can be given as following in a tapering way
(Epocrates, 2021):
60 mg orally per day (days 1 to 7)
30 mg per day (days 8-14)
15 mg per day (days 15-21)
Acetaminophen 1,000 mg by mouth every six hours as needed for pain (not to exceed 4,000 mg per day) (Epocrates, 2021)
Capsaicin 0.075% cream: Can be applied up to 4 times a day
Gabapentin 300 mg orally three times per day: if post-herpetic neuralgia occurs this can be considered and is safe for breastfeeding mothers (Epocrates,
2021).
Based on the likely diagnosis, what are your concerns about the other members of the family?
Because her children have not been vaccinated, they have the potential of getting this infection. Her mother is living with them and is seriously ill, therefore, I
am concerned about her mother getting this viral infection as well, especially if she has never had the chickenpox or chickenpox vaccine before. Not to
mention, her mother should have received the shingles vaccine as adults aged 50 and older should receive a two-dose vaccine series (CDC, 2022).
What patient teaching should you include?
The patient must be informed that valacyclovir does not prevent the spread of infection to others. Precaution should be taken around others who have not
had chickenpox or the varicella vaccine, or are immunosuppressed until all lesions have crusted over (Epocrates, 2021). Therefore, the patient should either
be very careful around her kids or have her older kids stay at a friend/family’s house if that is available to her and hopefully the house they are going to have
Which condition is the woman likely experiencing?
As mentioned in question 1, this patient is most likely experiencing herpes zoster, commonly known as shingles.
What treatment plan should you prescribe for the woman? Provide full prescriiption details.
Early intervention in the treatment of herpes zoster produces the best results, but we do not know the onset.
Valacyclovir 1000 mg po every 8 hours for 7 days can be prescribed as an antiviral to shorten the duration of viral shedding, stop the formation of new
lesions and reduce pain severity (Epocrates, 2021). Valacyclovir is also fine for breastfeeding mothers (Epocrates, 2021).
Prednisone may assist in reducing acute pain when given with antiviral therapy (Dunphy et al. 2019). Prednisone can be given as following in a tapering way
(Epocrates, 2021):
60 mg orally per day (days 1 to 7)
30 mg per day (days 8-14)
15 mg per day (days 15-21)
Acetaminophen 1,000 mg by mouth every six hours as needed for pain (not to exceed 4,000 mg per day) (Epocrates, 2021)
Capsaicin 0.075% cream: Can be applied up to 4 times a day
Gabapentin 300 mg orally three times per day: if post-herpetic neuralgia occurs this can be considered and is safe for breastfeeding mothers (Epocrates,
2021).
Based on the likely diagnosis, what are your concerns about the other members of the family?
Because her children have not been vaccinated, they have the potential of getting this infection. Her mother is living with them and is seriously ill, therefore, I
am concerned about her mother getting this viral infection as well, especially if she has never had the chickenpox or chickenpox vaccine before. Not to
mention, her mother should have received the shingles vaccine as adults aged 50 and older should receive a two-dose vaccine series (CDC, 2022).
What patient teaching should you include?
The patient must be informed that valacyclovir does not prevent the spread of infection to others. Precaution should be taken around others who have not
had chickenpox or the varicella vaccine, or are immunosuppressed until all lesions have crusted over (Epocrates, 2021). Therefore, the patient should either
be very careful around her kids or have her older kids stay at a friend/family’s house if that is available to her and hopefully the house they are going to have
residents who have all been adequately vaccinated. The 6-month-old she is breastfeeding will most likely need to stay with her, but she could pump if need be
and send milk with whoever is helping her with her kids. Not to mention, her lesions is on her left lateral side so she may be more comfortable pumping than
breastfeeding, and this may be safer for the child as well. If she sends her children to someone else, even for a few hours a day, she could get more rest and
care for herself. On that note, seeing if someone could help her with her mom can also be addressed. In addition to getting adequate rest, the patient should
be reminded of staying hydrated and eating a healthy diet.
References
Centers for Disease Control and Prevention (CDC). (2022). Shingles vaccination.
https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html#:~:text=CDC%20recommends%20that%20adults%2050,the%20complications%20fro
Dunphy, L., Winland-Brown, J., Porter, B., & Thomas, D. (2019) Primary care: The art and science of advanced practice nursing-an interprofessional approach
(5th ed.). F.A. Davis. ISBN-13: 978-0-8036-3801-3
Epocrates. (2021). Shingles. https://online.epocrates.com/results?query=shingles/treatment:%antiviral%20agents%20(ESAs)
Gaby, A., M.D. (2017). Shingles. Nutritional Medicine (pp. 379-393). Fritz Perlberg Press.
Macrae, A., Field, A., McDonald, J., Meurisse, E., & Porter, A. (2019). Differential diagnosis of vesicular skin rashes. Lancet (London, England), 2(7615), 313–
316. https://doi.org/10.1016/s0140-6736(69)90070-1
Smith, J. (2020). Shingles. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/shingles/symptoms-causes/syc-20353054