McPhee, S. J., & Papadakis, M. A. (2011). Current medical diagnosis and treatment (50th ed.). New York, NY: McGraw-Hill Medical. Rai, K. R., & Keating, M. J. (2012, January). Epidemiology and clinical manifestations of chronic lymphocytic leukemia. UpToDate. Retrieved from Turkoski, B. B., Lance, B. R., & Tomsik, E. A. (Eds.). (2010). Drug information handbook for advanced practice nursing (11th ed.). Hudson, OH: Lexicomp. Wolff, K., & Johnson, R. A. (2009). Fitzpatrick’s color atlas & synopsis of clinical dermatology (6th ed.). New York, NY: McGraw-Hill Medical. Appendix A Figure1: Genogram *** Please see separate word document for Genogram *** Appendix B 1: List of current medications Drug Dosage Indications/Directions Hydrocodone/Acetaminophen 5mg/325mg tablets 1 -2 tablets 4 – 6 hours po prn for pain Docusate Sodium 100mg Gelcaps 1 – 2 gelcaps at bedtime po prn for constipation (prevention) Vitamin D3 (Cholecalciferol) 5,000 unit gelcaps 1 gelcap daily po Valacyclovir 500mg tablets 2 tablets, 3 po for 7 days starting at first manifestation of herpetic rash Prochlorperazine maleate 10mg tablets 1 tablet po every 6 hours as needed for nausea Desitin Cream (40% zinc oxide) cream Apply to affected skin areas after gentle washing as needed for relief of discomfort. 2: Laboratory report of hematology on PC#1 encounter CBC with Manual Differential
Test Result Flag Range Units WBC *3.8 L 4.5 – 10.5 /mm3 RBC 3.98 3.69 – 5.13 /mm3 Hemoglobin 14.0 11.7 – 14.5 g/dL Hematocrit 38.9 34.1 – 44.3 % MCV *97.8 H 80.6 – 95.8 U3 MCH *35.1 H 27.1 – 33.1 pg MCHC 35.9 32.2 – 36.7 % RDW 12.1 10.3 – 12.9 % Platelets 152 143 – 314 /mm3 MPV *5.5 L 6.0 – 9.0 U3 % # 29.7 *1.1 L 19.4 – 42.9 1.2 – 3.0 % /mm3 Gran: % # 54.2 2.0 39.3 – 73.7 1.2 – 7.0 % /mm3 Mono: % # 10.9 0.4 4.4 – 12.7 0.2 – 0.8 % Eos: % # 1.6 0.1 0.6 – 7.3 0.0 – 0.4 % Baso: % # *3.6 *0.1 H H – 1.7 0.0 – 0.1 % Reflex YES 204.10 Manual Differential SEG manual 60 40-70 % Lymph manual 32 20-45 % Mono manual 8 2-10 % ANISO 1+ MACRO 1+ POIK 1+ Appendix C: Treatment Modalities/Considerations 1: Anti-viral agents considered to decrease length and severity of acute episode Agent: Acyclovir Famicyclovir Valacyclovir Foscarnet Dose: 800mg po 4 hourly (mostly given 5 x/day) 7-10 days po 8 hourly 7 days 1,000mg po 8 hourly 7 days 40mg/kg IV 8 hourly over 1 hour infusion 10 days Primary drug Inconvenience of frequent dosing requirement Pro-drug Considered more helpful (than acyclovir) in prevention of PHN Convenient dosing Pro-drug Contra-indicated for some patients Convenient dosing Pro-drug Only available for IV administration Reserved for cases resistant to acyclovir
Table 2: Treatment options for PHN – Oral administration Pharmacological category Tricyclic Antidepressants Anti-convulsants (with analgesic properties) Drug Nortriptyline Gabapentin (Neurontin) Pregabalin (Lyrica) Carbamazepine (Tegretol) Dose Start: (Maximum) 10-20mg QD 100mg TID po (600mg TID) 75mg QHS (300mg BID) BID (600mg BID) Reason why considered Limited support for use in conjunction with anti-virals during acute phase to prevent PHN Anti-neuralgic action Highly recommended for treatment of PHN Anti-neuralgic action Highly recommended for treatment of PHN Anti-neuralgic action Often used for treatment of PHN & Trigeminal neuralgia Warnings / Reason(s) why not selected Increased risk for eosinophilia, purpura and thrombocytopenia May also aggravate peripheral neuropathy May increase risk for leucopenia May take 2 -3 weeks to achieve optimal effectiveness. May increase risk for thrombocytopenia Contra-indicated for patients with bone marrow suppression. Warning: hypersensitivity may mimic signs & symptoms of lymphoma Other considerations Interacts with many other drugs Generic available Very few drug-drug interactions No generic available Expensive Interacts with many other drugs Final decision for this patient Not selected based on limited support and side-effect Most favored option – fewest interactions & EBP supported Not selected - too expensive Not selected based on side-effect profile Table 3: Topical preparations / options for treatment of PHN Treatment Lidocaine 5% Topical Aspirin Topical Capsaicin 0.075% cream How used / applied Patch applied to intact skin after resolution of blisters and crusts Aspirin tablets crushed & mixed into Vaseline / Eucerin cream Applied to intact skin after crusted lesions are healed Reason why considered May be useful on buttock once all lesions are completely healed. Used in many compounded topical treatments Not considered Warnings / Reason(s) why not selected Patient still has blisters & crusted lesions. Patch not recommended for Not considered for use in perineal / groin area
application on perineum/groin area Final decision for this patient May be useful at later time (after lesions are healed – use on buttock only) Used with success & will continue to use Not considered at all Table 4: Symptomatic measures utilized by the patient Measures utilized with success (Is going to continue with these) Unsuccessful measures (ineffective/aggravating) (Tried but discontinued) Desitin ointment (with 4% zinc oxide) Applying heat to area / taking warm bath/shower Cold, moist compresses (chilled, moist washcloths) Aloe Vera Gel, Calamine lotion Ice packs Balmex ointment (with 11% zinc Cornstarch powder Gold Bond powder Limiting mechanical irritation from clothes (wears loose-fitting clothes as tolerated) Benadryl cream, Aspercreme, Cortaid lotion, Vitamin E oil Aspirin tablets crushed & into Vaseline/Eucerin Applying sun lamp (ultra-violet light) for 5 minutes per day (aggravated symptoms) EFT (Emotionally Focused Therapy) Dimethyl sulfoxide (DMSO) 50% cream