Comprehensive Management of Herpes Zoster in a Geriatric Patient: A Case Study Paper

A 68-year-old male patient presented with thoracic pain and vesicular rash for one week’s duration, which is diagnostic of diseases like Herpes Zoster (Shingles), musculoskeletal pain, costochondritis, Herpes Simplex Virus infection, or contact dermatitis. The patient also explained sharp, burning pain within a dermatomal distribution and vesicular rash located on an erythematous base, for which the diagnosis is most likely Herpes Zoster. Comprehensive Management of Herpes Zoster in a Geriatric Patient: A Case Study Paper

Pathophysiology

It is an illness caused by the VZV. It gets itself reactivated after an initial attack of chickenpox, where it goes to the dorsal root ganglia (Kennedy, 2023). The disease re-emerges if the immune capacity of the affected individual lowers. The virus starts to multiply and is carried by the sensory nerves to the skin, which develops clusters of painful sores.

Diagnostic Tests and Imaging

Some investigations that should be done for a patient with Herpes Zoster include PCR or DFA for VZV, CBC, especially if the patient has an infection or immune issues, LFT in case there is a liver condition, and Chest X-ray if the patient has thoracic pain due to other causes, such as pneumonia empyema.

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Management and Treatment Options

The treatment of Herpes Zoster involves using antiviral in addition to analgesics and follow-up. Antiviral agents shorten the time of presenting signs and symptoms. Analgesics, therefore, includes NSAIDS, potent opioids, and antineuralgics. It is necessary to track exercise, nutrition, vital signs, changes in symptoms, side effects of the treatment, and overall health with an expert’s consultation.

Prevalence, Treatment, and Recurrence

 Herpes Zoster affects the elderly and immunocompromised patients, and about 30% of people develop shingles in their lifetime. Some options include antiviral agents for managing the acute phase, analgesics for pain, and topical agents for skin manifestations. Other signs include pain, itching, and the rash, which is the hallmark of this disease. A significant problem is postherpetic neuralgias, a syndrome of pain not infrequent after the rash has cleared up. Though rare, cases of reactivation of the Herpes Zoster have been reported mainly in Immunocompromised patients. Comprehensive Management of Herpes Zoster in a Geriatric Patient: A Case Study Paper

ICD-10 and CPT Codes

 Regarding the present visit, the relevant ICD-10 code is B02. 9 (Zoster without complications), and the CPT code is 99213, which denotes an evaluation and management visit to an office or other outpatient setting for a patient who is already established and has limited medical decision-making ability.

Patient Education

Some of the teachings that need to be imparted to the patient include that the chickenpox virus causes Herpes Zoster and is a reaction to the virus (Wahed, 2020). Stress should be made on the use of antiviral drugs and the necessity of beginning the intake of the medications as soon as possible, as well as following the prescribed treatment plan. Potential recommendations that can be made include the approaches to pain management in general and medications for neuropathic pain in particular. Further, the patient should be educated on the shingles vaccine (Shingrix) to avoid future occurrences.

Medical and Legal Concerns

If not handled properly, the patient can experience intense pain, long suffering, and other consequences such as postherpetic neuralgia, which would be considered as pain and suffering, and potential complications which can cause legal responsibility. Comprehensive Management of Herpes Zoster in a Geriatric Patient: A Case Study Paper

Interprofessional Collaboration

Therefore, this case requires management by different professionals in the health field. The primary care practitioner is the first to diagnose and treat a patient with the disorder. A skin doctor can validate the diagnosis and treat skin ulcers and other skin lesions. A pain specialist should be involved in the care of the patient where the pain is severe and, specifically, postherpetic neuralgia. A pharmacist plays an informative role primarily in educating the patient on the correct use of the drug as well as the side effects. If the patient has developed severe or repeated Herpes Zoster, an infectious disease specialist may be needed (Bridgeman & Wilken, 2021). This makes the patient’s management effective and efficient since it is collaborative care.

References

Bridgeman, M. B., & Wilken, L. A. (2021). Essential role of pharmacists in asthma care and management. Journal of Pharmacy Practice, 34(1), 149-162. https://journals.sagepub.com/doi/abs/10.1177/0897190020927274

Kennedy, P. G. (2023). The spectrum of neurological manifestations of varicella–zoster virus reactivation. Viruses, 15(8), 1663. https://www.mdpi.com/1999-4915/15/8/1663

Wahed, M. A. (2020). A Clinical Study of Herpes Zoster Ophthalmicus (Master’s thesis, Rajiv Gandhi University of Health Sciences (India)). https://search.proquest.com/openview/1d688269929a48c72dd2565349aea365/1?pq-origsite=gscholar&cbl=2026366&diss=y Comprehensive Management of Herpes Zoster in a Geriatric Patient: A Case Study Paper

PAINFUL RASH, GERIATRIC MALE
Chief Complaint
“Painful rash.”

History of Present Illness
A 68-year-old man presents to his PCP with a 1-week history of thoracic pain. He describes the pain as slow onset of symptoms on the right side of his thoracic spine radiating to his anterior trunk. The pain has progressively worsened, and he describes it as sharp and burning. He states the discomfort started a week ago as an ache after returning from work. He suspected a strained muscle and treated with warm packs and over-the-counter ibuprofen. In the subsequent days, his pain became worse, and he was concerned he had irreversibly injured his back. He denies any associated paresthesia or recent weight loss.

About 2 days ago, he noticed a mildly pruritic rash to his abdomen, and he was not sure if this was related to his pain. He states, “It even hurts to breathe now,” noting that positional changes make the pain worse. He states it is very tender to lay on his right side.

He is a fieldworker; he drives heavy equipment and supervises other workers. He is concerned he injured his back getting in or out of equipment, which occurs frequently during a normal workday. Comprehensive Management of Herpes Zoster in a Geriatric Patient: A Case Study Paper

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
The patient’s medical history is significant for well-controlled type 2 diabetes, hypertension, hyperlipidemia, and obesity. His surgical history is significant for cholecystectomy (age 48), colonoscopy, and upper endoscopy (age 65) revealing mild gastritis. He admits to usual childhood illnesses. Social history is significant for one to two beers after work daily. The patient quit smoking cigarettes at age 48 and denies recreational drug use. He is heterosexual with no history of sexually transmitted infections and enjoys a monogamous relationship with his wife. He has three grown children, nine grandchildren, and one great grandson. He resides in a single-story home with his wife. He is the primary wage earner. He states a granddaughter is reliant on him for college funding. His family history is unknown.

Allergies
No known drug allergies; no known food allergies. Comprehensive Management of Herpes Zoster in a Geriatric Patient: A Case Study Paper

Medications
Metformin 1,000 mg PO BID.
Glargine insulin 15 units SQ QD.
Atorvastatin 20 mg QD.
Lisinopril 20 mg PO QD.
Aspirin 81 mg PO QD.
Fish oil (omega 3) 1,000 mg PO QD.

Physical Examination
Vitals: T 37°C (98.6°F), P 88, R 14, BP 138/82, WT 85 kg (188 lbs), HT 170 cm (67 in.), BMI 29.

General: Spanish-speaking 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 2cm 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.

ENT/Mouth: Dentition in good repair. Gross hearing intact. Bilateral TMs patent.

Neck: FROM, trachea midline, no adenopathy.

Chest: Symmetrical, no axillary adenopathy.

Lungs: Clear to auscultation bilaterally. Good air movement discernible.

Heart: RRR, without murmur/gallop.

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: Protuberant. Moderate tenderness right upper quadrant and epigastric area to light touch. 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. Comprehensive Management of Herpes Zoster in a Geriatric Patient: A Case Study Paper

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Clinical Discussion Questions
1.What is the differential diagnosis?

2.What is the most likely diagnosis? Why?

3.Demonstrate your understanding about the pathophysiology in regard to the most likely diagnosis.

4.Should tests/imaging studies be ordered? Which ones? Why? Think about tests/imaging beyond the primary care setting as well.

5.What are the next appropriate steps in management?

6.Review reliable articles and investigate the prevalence, treatment options, associated symptom(s), and recurrence of the diagnosis. Include the name of the references.

7.What are the pertinent ICD-10 and CPT (E/M) codes for this visit? Provide a short rationale.

8.What are the appropriate patient education topics for this case?

9.If not managed appropriately, what is/are the medical/legal concern(s) that may arise?

10.Think about interprofessional collaboration for this case. Provide a list of specialties or other disciplines and indicate what contribution these professionals might make to managing the patient. Comprehensive Management of Herpes Zoster in a Geriatric Patient: A Case Study Paper