Transcript Case Presentation #1

Case Presentation #1
Madison Zuis
Nur 680
Client and Source of Encounter
•
•
•
•
•
Name= M.M.
Age = 24 years
Gender= female
Reason for visit= annual GYN physical
Setting = North Country OB/GYN, Glens Falls, NY
History of Present Illness
• Presents to office for annual GYN physical and PAP
• No GYN complaints
• No recent illness
• Seen in ER last week for “ingrown hair” in pubic region and treated with Doxyclycline
100mg po BID
• Finished antibiotics yesterday, area still red and swollen
• New “ingrown hair” appeared two days ago under left axilla
Review of Systems
• General- Thinks she had a fever in ER. Denies chills,
malaise, night sweats, appetite changes or weight gain.
• Respiratory- Denies pain, dyspnea, orthopnea, wheezing,
cough, sputum, hemoptysis, night sweats, asthma,
bronchitis, exposure to TB
• Cardiac- Denies heart murmurs, pain or palpitations,
dyspnea, or edema.
• Musculoskeletal- Denies pain. Denies gout, muscle pain,
redness, tenderness.
• Skin- Reports redness and warmth to left groin, pus-like
drainage from ingrown hair. Left axilla tender + warm ,
no open areas.
• Genital/Rectal-. Mons pubis without lesions/rash. Scarce
pubic hair present. Labia minora pink, no erythema,
matches skin tone. Perineum nontender, without lesions.
Labia majora without lesion or discharge. Clitoris,
midline. Urinary meatus pink, no discharge. Vaginal
opening pink and dry. Bartholins glands smooth, pink,
non tender. Cervix pink, symmetrical, smooth, and firm.
Positioning midline. Small cervical os. No discharge at
introitus; no lesions appreciated. Uterus palpable,
nontender. Rectum pink, free of discharge.
Past Medical History
• Medical Illness
• Polycystic Ovarian Syndrome( PCOS)
• Obesity ( BMI 32)
• Smoker ( 5 cigarettes day)
• Surgeries
• I+D 2012 left buttock
• Allergies
• NKDA
• Medications• Multivitamin daily
• Doxycycline 100mg BID x 7days
(completed)
Past Medical History
• Health Status
• View herself as healthy
• Would like to lose weight, started eating
breakfast daily
• Acknowledges need for smoking cessation
• Health Risks
• Obesity
• Little physical activity
• Smoking
• Disability
• None known- works as a house manager at a
group home
• Family Problems
• Parents divorced, lives with mother; does not
care for mothers new boyfriend ( ETOH
abuse)
• Sister is best friend
Family History
• Mother
• Obesity, breast CA, PCOS
• Father
• Unknown
• Sister
• Obesity, depression, anemia
• Maternal Grandparents
• Obesity, DM, HTN, MI, breast CA
• Paternal Grandparents
Differential Diagnosis
•
•
•
•
•
•
Catscratch disease
Actinomycosis
Cutaneous blastomycosis
Ersipelas
Granuloma Inguinale
Hidradenitis Suppurativa
( Medscape, 2014)
Redefining the Diagnosis
• Cat Scratch disease
• Tender regional lymphadenopathy
• Exposure to cats (2-8 weeks)
• 90% of patients develop one or more 3-5
mm red/brown non tender papules at
inoculation site
• Actinomycosis
• subacute-to-chronic bacterial infection
caused by filamentous, gram-positive, non–
acid-fast, anaerobic-to-microaerophilic
bacteria
• Most common cervicofacial ( lumpy jaw). In
women- pelvis usually from IUD
• Lower abdominal discomfort, abnormal
vaginal bleeding or discharge
(Medscape, 2014)
Redefining the Diagnosis
• Cutaneous blastomycosis
• systemic pyogranulomatous infection
usually caused by the inhalation of
spores (Blastomyces dermatitidis)
• Flu-like symptoms after exposure
• purplish-gray verrucous lesions with
heaped borders or friable lesions that
ulcerate.
• Ersipelas
• bacterial skin infection involving the
upper dermis that characteristically
extends into the superficial cutaneous
lymphatics
• Hx of trauma or recent pharyngitis
• C/o itching, burning, tenderness
(Medscape, 2014)
Redefining the Diagnosis
Granuloma Inguinale
• chronic bacterial infection that
frequently is associated with other
STDs
• Large painless ulcers, odor
(Medscape, 2014)
Hidradenitis Suppurativa
Hidradenitis Suppurativa
• Chronic, recurrent inflammatory disease characterized by painful
subcutaneous nodules
• Axillae
• Perineum
• Inframammary folds
( Li & Barankin, 2011)
Etiology / Incidence
• Rare, prevalence is thought to be about 1%
• Typically 2nd or 3rd decades develops, onset after menopause is rare, women tend to clear post menopause
•
Mean age of onset is around 23 years
• No clear racial predilection
•
Black skin, more aprocrine glands ( Topley & Brain 2013)
• 4xs more common in women than men
• 1/3 of people with HS have a blood relative with HS (AAD, 2014)
(Walls, et al 2010)
Pathophysiology
• Unknown cause- believed multifactorial
• Acne-like hyperkeratinistion of the follicular unit
•
•
•
•
Leads to occlusion and rupture
Release keratin, sebum, bacteria and hair into dermis
Inflammation and necrosis of the sebaceous and/or sweat gland
Results in inflammatory process that engulfs the apocrine gland
• Rupture of overlying skin, fibrosis and sinus tract formation
( Wall, et al 2010)
Signs and Symptoms
• Early
• One ( or several) breakouts that look
like pimples or boils
• Clear and reappear
• Late
• Painful deep breakouts that heal and
reappear
• Rupture and leak foul smelling fluid
• Scarring; scarring that becomes thick
• Spongy-like skin( sinus tract
tunneling)’
(AAD, 2014)
Diagnosis
• Hurley Staging system
• Stage 1
• Single or multiple abscesses without sinus tracts or scarring ( apprx 75% of patients)
• Stage 2
• Single or multiple widely separated abscesses; scarring and/or tract formation ( apprx 24%)
• Stage 3
• Diffuse or near diffuse involvement or multiple interconnected sinus tracts and abscesses across
an entire affected region ( apprx. 1%)
( Petrou, 2012)
Treatment
•
• Steroids
• Tumor necrosis factor-a inhibitors
• Fair evidence to support the use in Stage
Pharmological
•
•
Antibiotics
•
First line therapy
•
Fair evidence to support the use in an evidence based
review of the literature ( Alhusayen & Shear, 2012)
•
PO- tetrecylcines
•
Topical- 1% or 2% clindamycin BID x 3 months
Hormone therapy
•
Acutane
•
Estradiol 5omg in combination with norgesterol 500mg
(AOCD, 2014)
II-III; expensive, adverse-effect profile (
Alhusayen & Shear, 2012)
• Infliximab
• Etanercept
• adalimumab
(Walls, et al 2014)
Treatment
• NonPharmological
• I+D
• Carbon Dioxide laser therapy
• Destroys hair follicles, may take multiple treatments, expensive
• Wide surgical excision ( Stage III)
• Split thickness skin grafting
• Wound vac therapy currently being researched, small 5 case study showed success
( Alharbi, et al 2012)
Management/ Patient Education
• Avoid tight fitting clothes
• Keep skin cool
•
•
•
•
•
Weight loss
Smoking cessation
Stop shaving where breakouts occur
Stress management
Wound care- packing, drain care, etc
Education
Not contagious
Poor hygiene does not cause HS
Follow up and Referrals
• Dermatology
• General surgeon
• Counseling
• Body image
M.M. Visit
• Referral to General Surgeon and Dermatology
• Start BCPs
• Ortho-Cyclen 28 po daily
• Clindamycin 2% cream BID
• Follow up in 1 month
• Counseling considered
References
•
•
Alharbi, Z., Kauczok, J., & Pallua, N. (2012). A review of wide surgical excision of hidradenitis suppurativa, BMC Dermatology, 12(9) 211-219
•
American Academy of Dermatology (2014). Hidradenitis suppurativa. Retrieved February 21st, 2015 from http://www.aad.org/dermatologya-to-z/disease-and treatments/hirdradenitis-suppurativa
•
American Osteopathic College of Dermatology ( 2015). Hidradenitis Suppurativa. Retrieved
http://www.aocd.org/?page-HidradenitisSuppura
•
•
•
•
•
Li, K. & Barankin, B. (2011). Dermacase, Canadian Family Practice, 57(9) 1023-1026
Alhusayen, R. & Shear, N. (2012). Pharmacologic Intervention for Hidradenitis Suppurativa, American Journal of Clinical Dermatology, 13(5) 283291
February 21st, 2015 from
Medscape (2014). Hidradenitis Suppurativa, retrieved Febrauary 21st from http://medscape.org/hidradenitissuppurativa
Petrou, I. (2012). Algorithm provides quicker diagnosis of hidradenitis suppurativa, Dermatology, 12 (3)14-16
Topley, B. & Brain, S. (2013). Hidradenitis suppurativa: a case study, British Journal of Nursing, 22(15) 16-20
Walls,B., Mohammad, S., Campbell, J., Arcer,L., & Beale, J. (2010). Negative pressure dressing for severe hidradenitis suppurativa (acne
inverse): a case study, Journal of Wound Care, 19(10) 457-460