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A 38-year old African-AmericanWoman with Hidradenitis
Suppurativa RequiringSuppurativa Requiring Surgical Intervention
A Case StudySwae Witherspoon
NSG 6045 Practicum II
CASE FORMULATION
Case Selection
EncountersEncounters
Insurance
SUBJECTIVE
Patient Profile:38‐ year‐0ld African American female, “ Vickie”
Chief Complaint:“I have these very painful, foul smelling boils that d i i ”I ll t ti t f l are draining pus.”I am really starting to feel
depressed.”
OVERVIEWEarly signsP i d t dPain and tendernessPhysical examPhysical examLesion distributionPhysical/psychological sufferingQ lit f lifQuality of life
OVERVIEW CONT’D Hidradenitis suppurativa is a chronic, debilitating recurrent disease involving the apocrine‐bearing ki i h dil i f i i i skin with a predilection for intertriginous areas, including genital skin (Wiseman, 2004). According to (Wiseman 2004) genetic factors According to (Wiseman 2004), genetic factors, patient characteristics, hormones and infection play a role in disease expression, but a p y p ,comprehensive understanding of the pathogenesis remains elicit.
HS: ETIOLOGY
PrevalenceCommonalityPathogenesisPredisposing Factors
SUBJECTIVE: HPI
Clinic VisitEmergency Room g yVisitsSymptomsy p
SUBJECTIVE : FAMILY/ SOCIAL HISTORY Father , 63: healthy Mother, 60: healthy
• Immediate family in good health with some history of h i i di b d h iarthritis, diabetes, cancer and hypertension.
Si l th f t hild d h li ith h Single mother of two children and she lives with her boyfriend.
SUBJECTIVE: ROS General/Neurological: Patient denies‐chills, depression, fainting, fever,M l /J i /b P i d i i k Muscle/Joint/bone: Patient denies‐ pain, weakness, numbness
Genital Urinary: Patient denies blood in urine Genital‐Urinary: Patient denies‐ blood in urine, frequent urination, painful urination
Gastro‐Intestinal: Patient denies‐poor appetite, Gastro Intestinal: Patient denies poor appetite, constipation, diarrhea, nausea
Cardio‐Vascular: patient denies‐chest pain, HBP, LBP, poor circulation, swelling of ankles
SUBJECTIVE: ROS CONT’DHEENT: Patient denies‐ blurred vision, difficulty swallowing, ear discharge, sinus y g gproblems, or vision.
Skin: Patient denies‐ bruising easily hives; Skin: Patient denies bruising easily hives; admits to rashes, scars, and sores that will not healnot heal
ALLERGIES: NKDA
OBJECTIVE: PE Physical Exam: General: The patient is a well‐developed, well nourished black female in little to no apparent distressapparent distress.
Eyes: Conjunctiva and lids appear normal. ENMT: Lips tongue and gums appear normal ENMT: Lips, tongue, and gums appear normal. Lymphatic: no evidence of lymphadenopathy in neck. Extremities: Hands and nails appear normal Extremities: Hands and nails appear normal
OBJECTIVE : PE Neuro/Psych: Patient is oriented to person, place, and time and seemed interested in, although not severely depressed slightly anxious or agitated concerning the depressed, slightly anxious, or agitated concerning the skin condition.
SKIN: Large tender painful erythematous fistula SKIN: Large tender, painful, erythematous, fistula tracts and abscesses at the back of the sclap (neckline), behind the ear folds, axillae, and groin‐crural folds. Copius amounts of weeping is noted. Hypertrophic scarring is present. Post inflammatory hyperpigmentation is presenthyperpigmentation is present.
ASSESSMENT DIAGNOSIS:
Hidradenitis Suppurativa 705.83 Pruritus NOS 698.8 Hypertrophic Scar Pigmentary Disorder 709 00 Pigmentary Disorder 709.00
DIFFERENTIAL DIAGNOSIS:DIFFERENTIAL DIAGNOSIS: Skin Infections 684 Atrophy of Skin 701.3p y 3
INITIAL PLAN Dark discoloration ill partl remain Dark discoloration will partly remain. Explained the cause and the disease is not curable, but controllable It will usually and eventually go away in controllable. It will usually and eventually go away in time for most, but will most likely return.
Keep areas cool and dry, recommended antibacterial p ysoaps, loose fitting clothing and weight loss.
Emphasized the use of mild soaps, emollients. 70 mg kenelog injection IM. HS‐USA (www.hs‐usa.org). Stress management.
MEDICATIONS Levaquin 500 mg (disp: 30) Sig: Take one tablet Levaquin 500 mg (disp: 30) Sig: Take one tablet daily. Refills‐1.
Clindamycin (Topical Solution) Disp: 2 bottles‐y ( p ) p120cc. Sig: Apply to affected
areas of the body bid. Refills‐4. Centany Cream. Disp: 120gm. Sig: Apply to affected areas of the body bid. Refills‐3.D b b k (Di ) Si Di l Domeboro tabs or packs (Disp: # 90) Sig: Dissolve one in a pint of water and apply as a wet compress for 15 minutes three times daily (Refills‐4)for 15 minutes three times daily (Refills 4).
Darvocet‐N 100 (Disp: 20) Sig: Take one tab by mouth every 4‐6h as needed for pain.
FOLLOW‐UP CAREReturn to clinic in 4 weeks.Start intralesional injections at next office Start intralesional injections at next office visit.
11/09/2009Pt returns to clinic for F/U.
CONTINUITY OF CARESUBJECTIVE: mild to moderate change from previous visitp
OBJECTIVE: no change from previous visitASSESSMENT: no change from previous ASSESSMENT: no change from previous assessment
PLAN I i i d d i f b ( PLAN: Incision and drainage of abscess (eg, carbuncle, supporative hidradenitis,
t f b t b t cutaneous of subcutaneous abscess, cyst, furuncle, or paronychia); simple
:Medical Treatment Plan and Prognosis:Same as above except:4mg kenelog intralesional injections4mg kenelog intralesional injections.Introduced the need for a surgical procedure‐with the name and telephone number of surgeonp g
MEDICATIONS Same as above except: Clindamycin 300mg Disp: #60 Sig: Take one tablet by
h bid R fillmouth bid; Refills‐4. Rifampin 300mg Disp: #60 Sig: Take one tablet by mouth bid; Refills 4mouth bid; Refills‐4.
CASE CONCLUSIONSChronic Inflammationo Chronic Inflammation
o Depression
Continuity of care: Referred to plastics Continuity of care: Referred to plastics, reconstructrive surgeon.
QUESTIONS Because the research has noted HS to be a disease of recurrence, when should the advanced practice nurse refer a patient?nurse refer a patient?
Who do you think are affected more by the Who do you think are affected more by the disease process, and when is it typically most active?
REFERENCES AKSAKAL, A. B., & ADIŞEN, E. (2008). Hidradenitis suppurativa: Importance of early treatment; efficient treatment with electrosurgery.
Dermatologic Surgery, 34(2), 228‐231. Altmann, S., Fansa, H., & Schneider, W. (2004). Axillary hidradenitis suppurativa: A further option for surgical treatment. Journal of
Cutaneous Medicine & Surgery, 8(1), 6‐10. BUIMER, M. G., ANKERSMIT, M. F. P., WOBBES, T., & KLINKENBIJL, J. H. G. (2008). Surgical treatment of hidradenitis suppurativa with
gentamicin sulfate: A prospective randomized study.Dermatologic Surgery, 34(2), 224‐227.g p p y g g y, 34( ), 4 7 CONSTANTINOU, C., WIDOM, K., DESANTIS, J., & OBMANN, M. (2008). Hidradenitis suppurativa complicated by squamous celt
carcinoma. American Surgeon, 74(12), 1177‐1181. Getting a handle on hidradenitis suppurativa.(2009). Neurology Alert, , 18‐18. Herrington, S. (2007). Hidradenitis suppurativa. In M.R. Dambro (Ed), Griffith’s 5 minute Consult (14th ed.). Philadelphia: Lippincott and
Wilkins 570‐572. Hidradenitis suppurativa does a familial form with autosomal dominant inheritance really exist?(1999) Blackwell Publishing Limited Hidradenitis suppurativa‐‐does a familial form with autosomal dominant inheritance really exist?(1999). Blackwell Publishing Limited. HS‐USA. (2005). Hidradenitis suppurativa. The hidden disease. Retrieved November 1, 2009. from http://www.hs‐usa.org/home.htm. Jemec, G. (2000). What’s new in hidradenitis suppurativa? Blackwell Publishing Limited. Joseph, M. A., Jayaseelan, E., Ganapathi, B., & Stephen, J. (2005). Hidradenitis suppurativa treated with finasteride. Journal of Dermatological
Treatment, 16(2), 75‐78. Hidradenitis suppurativa‐‐does a familial form with autosomal dominant inheritance really exist?(1999). Blackwell Publishing Limited. HS‐USA. (2005). Hidradenitis suppurativa. The hidden disease. Retrieved November 1, 2009. from http://www.hs‐usa.org/home.htm. Jemec, G. (2000). What’s new in hidradenitis suppurativa? Blackwell Publishing Limited. Joseph, M. A., Jayaseelan, E., Ganapathi, B., & Stephen, J. (2005). Hidradenitis suppurativa treated with finasteride. Journal of Dermatological
Treatment, 16(2), 75‐78. Hidradenitis suppurativa‐‐does a familial form with autosomal dominant inheritance really exist?(1999). Blackwell Publishing Limited. HS USA (2005) Hidradenitis suppurativa The hidden disease Retrieved November 1 2009 from http://www hs usa org/home htm HS‐USA. (2005). Hidradenitis suppurativa. The hidden disease. Retrieved November 1, 2009. from http://www.hs‐usa.org/home.htm. Jemec, G. (2000). What’s new in hidradenitis suppurativa? Blackwell Publishing Limited. Joseph, M. A., Jayaseelan, E., Ganapathi, B., & Stephen, J. (2005). Hidradenitis suppurativa treated with finasteride. Journal of Dermatological
Treatment, 16(2), 75‐78.
REFERENCES CONT’D Krbec, A. C. (2007). Current understanding and management of hidradenitis suppurativa. Journal of the American Academy of Nurse Practitioners,
19(5), 228‐234. Lam, J., Krakowski, A. C., & Friedlander, S. F. (2007). Hidradenitis suppurativa (acne inversa): Management of a recalcitrant disease. Pediatric
Dermatology, 24(5), 465‐473. Madan, V., Hindle, E., Hussain, W., & August, P. J. (2008). Outcomes of treatment of nine cases of recalcitrant severe hidradenitis suppurativa with
carbon dioxide laser. British Journal of Dermatology, 159(6), 1309‐1314. Krbec, A. C. (2007). Current understanding and management of hidradenitis suppurativa. Journal of the American Academy of Nurse Practitioners,
19(5), 228‐234. Lam, J., Krakowski, A. C., & Friedlander, S. F. (2007). Hidradenitis suppurativa (acne inversa): Management of a recalcitrant disease. Pediatric
Dermatology, 24(5), 465‐473. Madan, V., Hindle, E., Hussain, W., & August, P. J. (2008). Outcomes of treatment of nine cases of recalcitrant severe hidradenitis suppurativa with
carbon dioxide laser. British Journal of Dermatology, 159(6), 1309‐1314. McAllister, M. (2003). Hidradentitis suppurativa (acne inversa). In T.M. Buttaro, J. Trybulski P.P. Bailey, & J. Sandberg‐Cook (Eds.). Primary care: A
collaborative practice (2nd ed.). St. Louis, MO Mosby, 235‐237. Mendonça C O & Griffiths C E M (2006) Clindamycin and rifampicin combination therapy for hidradenitis suppurativa British Journal of Mendonça, C. O., & Griffiths, C. E. M. (2006). Clindamycin and rifampicin combination therapy for hidradenitis suppurativa. British Journal of
Dermatology, 154(5), 977‐978. Sellheyer, K., & Krahl, D. (2005). “Hidradenitis suppurativa” is acne inversa! an appeal to (finally) abandon a misnomer. International Journal of
REFERENCES CONT’D McAllister, M. (2003). Hidradentitis suppurativa (acne inversa). In T.M. Buttaro, J. Trybulski P.P. Bailey, & J. Sandberg‐Cook (Eds.). Primary
care: A collaborative practice (2nd ed.). St. Louis, MO Mosby, 235‐237. Mendonça, C. O., & Griffiths, C. E. M. (2006). Clindamycin and rifampicin combination therapy for hidradenitis suppurativa. British Journal of
Dermatology, 154(5), 977‐978. Sellheyer, K., & Krahl, D. (2005). “Hidradenitis suppurativa” is acne inversa! an appeal to (finally) abandon a misnomer. International
Journal of of Dermatology, 44(7), 535‐540. Sellheyer, K., & Krahl, D. (2008). What causes acne inversa (or hidradenitis suppurativa)? – the debate J f f gy, 44(7), 535 54 y , , , ( ) ( pp )continues. Journal of Cutaneous Pathology, 35(8), 795‐797.
Seneviratne, S. A., & Samarasekera, D. N. (2009). Hiradenitis suppurativa presenting as a polypoidal lesion at the anal verge. Colorectal Disease, 11(1), 97‐98. Shah, N. (2005). Hidradenitis suppurativa: A treatment challenge. American Family Physician, 72, 1547‐152. Von, D. W., & Jemec, G. B. E. (2001). Morbidity in patients with hidradenitis suppurativa.
B iti h J l f D t l ( ) 8 8 British Journal of Dermatology, 144(4), 809‐813. Wiseman, M. C. (2004). Hidradenitis suppurativa: A review. Dermatologic Therapy, 17(1), 50‐54. www.jaapa.com/hidradenititis‐suppurativa Balik, Emre., Eren, T., Turker, B., Buyukuncu, Y., Burga, D., & Yamaner, S. (2009). Surgical Apprach to Extensive
Hidradentitis Suppurativa in the Perineal/Perianal and Gluteal Regions. World Journal of Surgery, 33:481‐487. Solanki, N.S., Roshan, A., & Malata, C.M. (2009). Pedicled gracilis myocutaneous flap for treatment of recalcitrant hidradenitits suppurativa of Solanki, N.S., Roshan, A., & Malata, C.M. (2009). Pedicled gracilis myocutaneous flap for treatment of recalcitrant hidradenitits suppurativa of
the groin and perineum. Journal of Wound Care. (18)3, 110‐112.
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