Friday, January 05, 2007

Varicella Strikes Again

Today I received a call from a patient whose appointment yesterday with his primary physician was cancelled for reasons unknown. He was quite distressed since he was experiencing severe discomfort on the right side of his torso and felt like he was about to lose his mind with the pain. I told him to come on over.

He grimaced as he sat in the chair next to me. His wife looked concerned.

"So, when did the pain start?" I asked.

"About two weeks ago," he replied. "And there was this rash under here, but now it's gone." He points to his ribcage, around the 6th and 7th ribs, I think.

His wife chimes in. "It was like a bruise, with little red spots. He was in so much pain, and he would sweat all night. I couldn't even touch that area, he would scream in pain. Then the rash went away but the pain didn't change."

My mind clicked into action. "Did you have chicken pox that you know of? Most people have."

"Oh, yeah, when I was 18. Kind of late, and it was really bad."

I take his temperature: 99.1. Low-grade fever, with pain along the line of three ribs on one side, the right arm also affected.

"I think you have Shingles," I propose.

He looks puzzled.

In my best Spanish, I explain how the varicella virus lives for decades in the basal root ganglia of the spine, bursting forth when we're older with intense pain and lesions along what we call a "dermatome" where the nerve travels from the spine along the rib to the chest wall. It's technically called Herpes Zoster.

I fetch a doctor, the same one with whom the appointment was cancelled the other day. He readily agrees with my diagnosis. Since the rash is gone, our plan is just to treat the significant pain with oxycodone and amitriptyline.

As a nurse, we are really not supposed to diagnose---only a doctor or Nurse Practitioner can do that. However, there are times when it is just so blatantly obvious that we can't help it. This was one of those times, and although I strive for humility in life, I couldn't help but feel some professional pride that I had hit the diagnostic nail on the head so definitively. A decade of experience does indeed begin to pay off eventually. Even amidst the stressors and struggles of the working life, the mountains of paperwork and avalanches of need, a simple and straightforward resolution to a problem presented in the examining room can offer a moment of great professional satisfaction. This was one of those times, and it lifted my spirits on an exhausted Friday afternoon.

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