Case Presentation

Family Medicine
 Case #1
22 years old white male presented to primary care physician with a painful
itchy erythematous skin rash mainly in the left axilla.
Several smaller papular blisters are also visible on the left side of the face and
the left buttock.
Low grade fever was present before rash appeared.
 Patient is diagnosed clinically with Shingles. (through visual confirmation,
not many disease produces rash in a dermatome pattern)
Other diagnostic tools include Tzanck smear, PCR and presence of VZV-
specific IGM in more difficult cases.
Patient was treated with aciclovir (5x 800mg a day) and chloramphenicol(due
to bacterial superinfection). Paracetamol were also prescribed to treat the
pain.
 Shingles
Caused by reactivation of Varicella Zoster Virus which lies dormant in the
dorsal root ganglia.
When it reactivates it produces blisters at the nerve endings in the skin.
Risk factors: old age, immunocompromised, chickenpox before 18 months
of age.
Exposure to the blisters may cause chickenpox in someone who has not had
it before.
 Clinical Presentation
Earliest symptoms include fever, malaise or headache. (Non specific
symptoms.
Usually followed by burning pain, itching, hyperesthesia, or paraesthesia of
affected dermatome. (Can be painless in children)
Rash can appear like hives at first and later becomes vesicular. Later crust
after a week.
 Complications
If the trigeminal nerve is involved, corneal involvement should be suspected,
especially if lesions appear at the tip of the nose. (May cause permenant
blindness.
Other complications: Postherpetic neuralgia, Disseminated shingles
 Treatment
Aciclovir
Analgesics
Antibiotics (if bacterial superinfection present)
 Sources
Hamborsky J (2015). Epidemiology and Prevention of Vaccine-Preventable
Diseases (PDF) (13 ed.). Washington D.C. Public Health Foundation.
pp. 35374. Archived (PDF)from the original on 2017-01-20.
^ Jump up to: a b c d "Shingles (Herpes Zoster) Signs & Symptoms". May 1,
2014. Archived from the original on 26 May 2015. Retrieved 26 May 2015.
^ Jump up to: a b c d e Cohen, JI (18 July 2013). "Clinical practice: Herpes
zoster.". New England Journal of Medicine. 369 (3): 25563. PMC 4789101
 Case #2
36 years old white female presents to the primary care physician complains
of burning urination, increased frequency and urgency.
No fever, no lower back pain, negative goldflams sign.
Patient is not pregnant.
Slight tenderness above pubic bone upon physical examination.
 Patient was diagnosed clinically with uncomplicated acute cystitis and was
given a short course of fosfomycin.(TMP/SMX and nitrofuratoin may also
be used)
 Acute cystitis
Infection of the lower urinary tract most commonly by E.coli. When upper
urinary tract is involved it is known as pylonephritis.
Risk factors include female anatomy, sexual intercourse, diabetes, obesity and
family history. Urine catherization is also an important risk factor.
Diagnosis is based mainly on clinical symptoms. In some complicated cases,
urine culture and urine analysis can be performed.
Recurrence of disease is common.
 Symptoms
Burning urination, frequency and urgency are typical presenting symptoms.
May be with or without fever, lower back pain, nausea or vomiting.
In children the only symptoms may be fever, so a urine culture is usually
indicated. Infants may feed poorly, vomit, or sleep more. Loss of bladder
control may be present in older children.
 Treatment
Antibiotics are the main treatment. Nitrofuratoin, TMP/SMX, and
fosfomycin should all be considered. Symptoms should improve after 36
hours. 50% of patients symptoms improve without any treatment.
In asymptomatic patients, antibiotics should not be given unless patient is
pregnant patients( risk of pyelonephritis, low birth weight and preterm
babies).
 Differential diagnosis
Cervicitis, vaginitis.
Urethritis in young men. (infection by C. trachomatis or N. gonorrhoea
Prostatitis.
 Sources
"Urinary Tract Infection". CDC. April 17, 2015. Archived from the original on 22
February 2016. Retrieved 9 February 2016.
^ Jump up to: a b c d e Flores-Mireles, AL; Walker, JN; Caparon, M; Hultgren, SJ
(May 2015). "Urinary tract infections: epidemiology, mechanisms of infection and
treatment options.". Nature Reviews. Microbiology. 13 (5): 269
84. PMID 25853778. doi:10.1038/nrmicro3432.
^ Jump up to: a b c d e f g Colgan R, Williams M, Johnson JR (2011-09-01).
"Diagnosis and treatment of acute pyelonephritis in women.". American family
physician. 84(5): 51926. PMID 21888302.