You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


Introduction
============

Herpes simplex virus (HSV) typically presents as a localised vesicular eruption or ulceration a few days after exposure. There are a number of differential diagnoses including mycobacterium tuberculosis, wegener\'s granulomatosis, invasive fungal disease and leprosy. In immunocompromised patients the clinical presentation is often atypical and lesions may be chronic. Early diagnosis and appropriate management improve outcome. Depending on the anatomical location of the lesions referral to other specialties for example ENT, Dermatology, Maxillofacial and Ophthalmology may be indicated.

Case presentation
=================

A 27-year-old Burmese woman who had been living in the United Kingdom for 2 years presented to the Accident and Emergency department with increasing nasal pain and fever. 7 days prior to presentation she sustained local trauma to the side of her nose from a button. Over the next 2 days this became a blister covering most of her nose, which then burst. During the following three days the skin over her nose in the distribution of the nasociliary nerve broke down. From the second day she was being treated with oral Amoxicillin 500 mg TDS and topical Neomycin sulphate cream (prescribed by her General Practitioner). She was taking simple analgesia - Paracetamol and Ibuprofen as required.

On examination there was erythema of the nose extending from the radix and both medial canthus to the alar rims. Within this there was a crusted, de-epithelialised paraesthetic area of skin approximately 3 × 2 cm square. There was no intranasal involvement on nasal endoscopy. She had a temperature of 37.9°C, white blood cell count of 10 (×1000/uL) and a C-reactive protein of 14 mg/L. Broad spectrum intravenous antibiotics were commenced. Figure [1](#F1){ref-type="fig"}, Figure [2](#F2){ref-type="fig"}, Figure [3](#F3){ref-type="fig"} show clinical images of the progression of the infection and the significant skin damage that occurred.

![**9th February 2009**.](1757-1626-2-9079-1){#F1}

![**13th February 2009**.](1757-1626-2-9079-2){#F2}

![**16th February 2009**.](1757-1626-2-9079-3){#F3}

On Day 1 a dermatology opinion was sought and a provisional diagnosis of herpes simplex made based on the clinical findings. The patient was started on 5 mg/kg intravenous Aciclovir TDS and isolated to a side-room as a precaution. Viral serology and a swab were sent for analysis and culture. On day 2, since there was no clinical improvement topical Aciclovir was added to the treatment regimen. Serologically herpes simplex virus (HSV) IGM and IGG antibodies were detected. The enzyme immunoassay (EIA) value for HSV IGG type 1 was 1.23 where a value \<0.9 is negative, 0.9 - 1.1 is equivocal and \>1.1 is positive. Diagnosis was confirmed by HSV 1 DNA detection on polymerase chain reaction (PCR) of the skin swab (2 weeks later).

At 8 week follow up there was complete re-epithelialisation and minimal scarring (see figure [4](#F4){ref-type="fig"}). The patient was instructed to avoid direct sunlight exposure and massage the area with Vaseline or E45 cream to help further improve the cosmetic appearance.

![**8^th^April 2009**. Taken in the outpatient department 2 months after hospital admission showing the patient\'s healed nasal skin.](1757-1626-2-9079-4){#F4}

Discussion
==========

Herpes simplex virus has two subtypes; HSV1 is more common and generally causes ulceration around the mouth or nose known as cold sores whereas HSV2 is more likely to cause genital lesions. Via a similar pathological mechanism to varicella zoster, there is the possibility of latent and recurrent disease. Following primary infection the virus lies dormant in dorsal root ganglia of sensory nerve fibres. In response to a number of possible triggers the immune system is no longer able to contain latent viral replication and the virus is reactivated. Possible triggers are sunlight, immunosuppression, stress, fever and menstruation.

Diagnosis of HSV can be made on clinical presentation, direct fluorescent antibody assay, tissue culture, histopathology with immunohistochemistry, electron microscopy or PCR. Serology alone may give a high number of false positives as there is a high prevalence of HSV antibody in the normal population. Unusual presentations of HSV usually occur in immunocompromised individuals and in the literature have particularly been described in association with fludarabine chemotherapy and patients with lymphoma \[[@B1]\]. Rarely necrosis can occur and surgical debridement is necessary \[[@B2]\].

Conclusion
==========

To our knowledge this is the first published case of severe nasal herpes simplex infection in an immunocompetent individual. It is important that we are aware of this unusual nasal presentation of a common viral pathogen and are therefore able to instigate early anti-viral therapy to reduce associated morbidity.

Consent
=======

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests
===================

The authors declare that they have no competing interests.

Authors\' contributions
=======================

HP and JA were the registrar and consultant looking after the patient during their hospital admission. HP took the clinical photographs, gained the patient\'s consent, and wrote up the manuscript with constant guidance and support from JA. Both authors have read and approved the final manuscript.