Summative Cases
Summative Case #1
Renee Biedlingmaier, DNP, MNE, RN, FNP-BC and Elizabeth Heavey, PhD, RN, CNM
Clinical Scenario
Nurse Practitioner (Sarah): Good morning, Mrs. Takahashi. I understand you’re here because of a rash and some pain. Can you tell me when you first noticed the rash?
Patient (Mrs. Takahashi): It started about three days ago. At first, it was just a small patch of red skin and it tingled, but then these blisters started.
Sarah: I see. Has the rash been spreading or changing since it first appeared?
Mrs. Takahashi: Yes, it seems to be getting worse. The blisters are more numerous now and the area is very painful.
Sarah: How would you describe the pain? Is it burning? Stabbing? Throbbing?
Mrs. Takahashi: It’s a burning pain, and it’s quite severe. Sometimes it feels like sharp, stabbing pains, too.
Sarah: On a scale of 1 to 10, with 10 being the worst pain imaginable, how would you rate your pain?
Mrs. Takahashi: I’d say it’s about an 8.
Sarah: Have you experienced any other symptoms, like fever, headache, body aches, joint pain, or fatigue?
Mrs. Takahashi: I’ve had a mild fever and a bit of a headache. I’ve also been feeling more tired than usual.
Sarah: Have you had chickenpox before?
Mrs. Takahashi: Yes, I had it when I was a child.
Sarah: Do you have any medical conditions?
Mrs. Takahashi: Yes, I take losartan for my blood pressure.
Sarah: Do you take any other medications? Anything over the counter?
Mrs. Takahashi: No other medications other than Tylenol occasionally. I haven’t taken any today. I took some last night when my head was hurting.
Sarah: Have you been under any significant stress recently or had any other illnesses?
Mrs. Takahashi: Well, my husband was just laid off. I was hoping to retire next year, but I think I will need to keep working unless he finds another position. We are doing okay, though. We’ve handled worse before. We’ve been married 40years now.
Sarah: That must be stressful for both of you. I’m glad you have each other for support. Have you been in contact with anyone who has chickenpox or shingles recently?
Mrs. Takahashi: No, I haven’t.
Sarah: Do you live alone or with others?
Mrs. Takahashi: I live with my husband.
Sarah: Does your husband have a rash?
Mrs. Takahashi: No, just me. He is worried I’m going to give it to him.
Sarah: How has the pain and rash affected your daily functioning or sleep?
Mrs. Takahashi: It has been hard to sleep much because of the pain.
Sarah: Have you tried anything to manage the pain? Has anything helped?
Mrs. Takahashi: Just the Tylenol, but it doesn’t seem to help much so I don’t take it very often. Sometimes I put ice on the rash. I tried some lotion the first night because I thought I had some dry skin, but that didn’t help. Then it was stinging, so I stopped putting anything other than ice on it. Oh, and a bandaid in the beginning.
Sarah: Have you received the shingles vaccine?
Mrs. Takahashi: No, I haven’t.
Sarah: Do you have any allergies to medications or vaccines?
Mrs. Takahashi: No, I don’t have any allergies.
Case Study
Patient Profile
Name: Mrs. Akari Takahashi
Age: 65
Sex: female
History of Present Illness
Mrs. Takahashi is a 65-year-old woman who presents to the clinic with a painful, blistering rash on her left torso. Mild fever, headache, and fatigue.
General Appearance: Patient is well nourished and in no acute distress. She is alert and oriented to person, place, and time. She has noticeable discomfort when the affected area is touched.
Medical History
Hypertension, menopausal x9 years, history of chickenpox in childhood.
Current Medications
Losartan, periodic Tylenol use.
Physical Examination
Vitals
- Temperature: 101°F (38.3°C)
- Heart rate: 94 bpm
- Respiratory rate: 20 bpm
- Blood pressure: 138/82 mm Hg
General Survey
- Skin
- Unilateral vesicular rash of grouped, clear vesicles on erythematous base, no discharge noted, some crusting present, follows a dermatomal pattern on the right side of the torso. Severe, burning pain in the area of the rash 7/10, pain with palpation, skin is warm to touch.
- No regional lymphadenopathy noted.
- Skin is slightly dry with some actinic keratosis observed on the forearms and face. No suspicious lesions noted.
- Head and Neck Examination
- Eyes: No significant cataracts noted; visual acuity is 20/30 in both eyes, no lesions on eyelids, no orbital edema.
- Nose: No lesions on nose, negative Hutchinson’s sign.
- Ears: Hearing is intact. No cerumen impaction observed.
- Mouth: Oral mucosa is moist. No lesions or cavities noted. Gums are slightly inflamed but no significant dental issues.
- No nuchal rigidity or lymphadenopathy.
- Musculoskeletal Assessment
- Gait is steady; no signs of ataxia.
- Chair stand test completed without difficulty.
- Grip strength measured at 25 kg on the right and 24 kg on the left.
- Neurological Examination
- The patient reports a pain level of 7/10 in the affected area.
- Light touch and pinprick sensation are diminished in the affected dermatome.
- No motor weakness observed; strength is 5/5 in all extremities.
- Deep tendon reflexes are intact and symmetrical.
- Cognitive Assessment
- The patient passed the Mini-Cog test with a score of 5/5 (recall of three words, clock drawing is accurate).
Diagnostic Testing
PCR Testing: Positive for Varicella Zoster Virus (VZV) DNA. (optional)
Complete Blood Count (CBC): normal
Primary Diagnosis: Herpes Zoster (Shingles)
Treatment Plan
- Antiviral therapy: Valacyclovir 1000 mg by mouth every 8 hours daily for 7 days.
- Pain management: Gabapentin 300 mg daily, up-titrateas needed. Topical lidocaine patches for localized pain relief.
- Supportive care: Rest and hydration.
- Discussed recommendation of vaccination with Shingrix for her spouse because he is over age 50. While shingles itself is not highly contagious, the Varicella Zoster Virus (VZV) can be transmitted from the shingles rash to someone who has never had chickenpox or the chickenpox vaccine, causing them to develop chickenpox. Vaccination reduces the overall risk of VZV transmission. The vaccine can also help prevent complications associated with shingles, such as postherpetic neuralgia (PHN), which can cause long-term pain.
- Follow-Up: Re-evaluate in one week to assess response to treatment.
- Once resolved, Shingrix vaccination is recommended for the patient to prevent future occurrences.
Patient Education About the Virus
About 1 out of 10 people with shingles will get something called “post herpetic neuralgia,” or “PHN.” People with PHN keep feeling pain or discomfort even after their rash goes away. This pain can last for months or even years. It can be so severe that it makes it hard to sleep, causes weight loss, and leads to depression. Patients who experience this should return for an evaluation and treatment.
Patients should not touch other areas of their body if they touch their rash. They should make sure to wash their hands. Eye infections with the virus that causes shingles can be serious and can lead to vision loss. Though rare, the virus can cause problems with the brain. If patients are concerned about either of these conditions, patients should call for an appointment. Patients should not use creams, lotions, gels, or ointments on the rash.
To prevent transmission, it is important to cover the rash, avoid touching or scratching the blisters, and maintain good hygiene. People with shingles should avoid contact with individuals who have never had chickenpox, pregnant women, newborns, and immunocompromised individuals until the rash has crusted over. Patients with shingles can transmit the virus to others who have not had chickenpox or varicella vaccination and cause them to develop varicella (chickenpox).
Activity: Special Concerns With Herpes Zoster
Fill in the blanks with the correct term: Hutchinson’s sign, uveitis, hypertensive, immunosuppressive, pannus, Chandelier sign
If the rash involved the face, forehead, or eyelids, the NP would perform a cranial nerve assessment. She would also check orbital edema which is an emergency if present. Also, lesions on the tip or side of the nose, _________________________, may indicate potential eye involvement since the nose and the cornea are both innervated by the trigeminal nerve. If the ophthalmic division of the trigeminal nerve is involved (Herpes Zoster Ophthalmicus), an emergent and thorough ocular examination must be prioritized to check for signs of _________________________, keratitis, and other ocular complications. All patients with signs of ophthalmic involvement should be referred for an urgent ophthalmologic evaluation to prevent potential vision loss.
The appearance of herpes zoster lesions may vary in different skin tones. On darker skin, inflammatory lesions may appear brown, grey, purple, or black, rather than the redness seen in lighter skin such as this patient. Additionally, immunocompromised patients require closer monitoring due to increased risk associated with varicella zoster infection, including atypical presentations, disseminated infections, and prolonged healing times. _________________________ medication may need to be temporarily held to promote healing and avoid disseminated infection.
Activity: Pathophysiology of Varicella Zoster and The Immune Response
Fill in the blanks with the correct term: initial, reactivation, dorsal root ganglia, SA node
Varicella Zoster Virus (VZV) is a member of the herpesvirus family. It causes two distinct diseases: varicella (chickenpox) upon _________________________ infection, and herpes zoster (shingles) upon _________________________. VZV enters the body through the respiratory tract, replicates in the nasopharynx and regional lymph nodes and then spreads to the skin, causing chickenpox. After primary infection, latency occurs, where VZV remains dormant in the _________________________ and can reactivate years later, especially when the immune system is compromised. Reactivation allows the virus to travel along the sensory nerves to the skin and causes inflammation and a vesicular rash. Factors such as aging, stress, or immunosuppression can trigger the reactivation of the virus, leading to shingles. During reactivation, the virus travels along the nerve fibers to the skin, causing the characteristic painful rash.
Activity: Shingles Vaccination
Fill in the blanks with the correct term: direct, indirect, 50, 65, 2, 3, have, have not, 2 to 6, 6 to 12
The risk of viral transmission is lower compared to chickenpox because shingles is less contagious and requires _________________________ contact with the rash. The virus is not spread through respiratory droplets in the case of shingles.
The Centers for Disease Control and Prevention (CDC) recommends vaccination with recombinant zoster vaccine (Shingrix) for adults ages _________________________ and older or immunocompromised adults ages 19 and older. Shingrix is administered in _________________________ doses, with the last dose given _________________________ months after the first.
Individuals who _________________________ had shingles should still receive the Shingrix vaccine to help prevent future occurrences of the disease. However, the vaccine should not be administered during an active shingles outbreak. The patient should wait until the shingles rash has completely healed before getting vaccinated.
Activity: Shingles Pharmacology Plan
Fill in the blanks with the correct term: 24, 72, postherpetic neuralgia, 7, kidney, liver
An acceptable first-line treatment in this situation is: Valacyclovir 1000 mg by mouth every 8 hours daily for 7 days. Antivirals are the most effective when started within _________________________ hours of the onset of the rash. Early initiation of antiviral medication can help reduce the duration of the disease and the risk of complications such as _________________________
Valacyclovir is only available in tablet formation at this time. If the patient has difficulty swallowing, the provider may need to go to acyclovir (Zovirax), available in an oral suspension.
Valacyclovir is rapidly and nearly completely converted to acyclovir by intestinal and hepatic metabolism. The antiviral action happens due to the agent interfering with DNA synthesis.
Appropriate treatment goals include the resolution of shingles rash within _________________________ days and for the patient to remain free from bacterial superinfection of shingles lesions for the seven days of treatment.
Monitoring Valacyclovir
If the patient has no known renal impairment and reports, no known _________________________ disease and is not on concomitant nephrotoxic agents, there is no need to get baseline labs.
Even in the setting of cirrhosis there is no dose adjustment. Renal adjustments are limited to those such as: elderly, underlying renal disease with higher than usual doses, concomitant nephrotoxic agents, and those that are dehydrated. This patient is 65 so there is likely baseline renal function in the chart. If not, the NP should consider ordering a renal panel.
Activity: Patient Education About Valacyclovir
Fill in the blanks with the correct term: kidney, liver, non-steroidal anti-inflammatory drugs, topical creams
Common adverse effects for Valacyclovir include: belly pain, nausea, lower neutrophils (a type of white blood cell), liver problems, headache, and inflammation of the tissues in the nose and/or throat. Teach the patient to report or seek emergency care if the patient experiences belly pain, nausea, yellow or itchy skin, dark urine, fever, sore throat, agitation, hallucinations, confusion, seizures/convulsions/fits/shaking uncontrollably, or passing out.
Patients taking Valacyclovir should avoid medications that may impair _________________________ function like _________________________ such as ibuprofen and naproxen.
Just a reminder to always instruct patients about potential for allergic reactions and that new symptoms that do not otherwise make sense to them are a reason to contact the provider. If there are urgent concerns like swelling of the mouth, lips, tongue, or trouble breathing, they should seek emergency care.
Review Questions
Click the arrow to expand the section and view the correct answers.
- When was Mrs. Takahashi likely infected?
- 2-6 months ago.
- In the last 7-10 days.
- This is a reactivated infection from childhood.
- When she was vaccinated.
Answer:
C. This is a reactivated infection from childhood.
Feedback: Herpes zoster represents reactivation of latent varicella-zoster virus rather than a new or recent infection. After primary varicella infection—typically occurring in childhood—the virus remains dormant in the dorsal root ganglia. Decades later, often due to age-related immune decline or physiologic stress, VZV can reactivate and present as shingles. The timeline of blister onset does not reflect initial infection but rather the point of viral reactivation
- Which diagnostic test is most definitive for confirming VZV reactivation?
- Blood glucose test
- Urine culture
- PCR testing
- Complete blood count
Answer:
C. PCR testing
Feedback: Polymerase chain reaction (PCR) testing of vesicular fluid is the most sensitive and specific diagnostic modality for confirming VZV reactivation. While herpes zoster is often a clinical diagnosis, PCR provides definitive confirmation, particularly in atypical presentations or immunocompromised patients.
- What is the primary treatment for herpes zoster?
- Antibiotics
- Antivirals
- Antifungals
- Steroids
Answer:
B. Antivirals
Feedback: Antiviral therapy targets viral replication to shorten disease duration, lessen symptom severity, and reduce complications such as postherpetic neuralgia. Antibiotics, antifungals, and steroids do not treat the viral etiology and are not first-line therapies. Steroids may be used adjunctively in select cases, but should not be used alone.
- Which medication is prescribed for pain management in this case?
- Ibuprofen
- Gabapentin
- Acetaminophen
- Aspirin
Answer:
B. Gabapentin
Feedback: Gabapentin manages neuropathic pain associated with herpes zoster. NSAIDs and acetaminophen may offer limited benefit but are often insufficient for the severe burning and shooting pain characteristic of zoster-related neuralgia. Aspirin is not preferred due to bleeding risk and limited efficacy for neuropathic pain.
- What is the typical duration of antiviral therapy for herpes zoster?
- 3-5 days
- 7-10 days
- 14-21 days
- 1 month
Answer:
B. 7-10 days
Feedback: A 7–10 day course of antiviral therapy is standard for uncomplicated herpes zoster in immunocompetent adults. Shorter courses risk incomplete viral suppression, while longer durations are generally unnecessary unless the patient is immunocompromised or has ongoing lesions.
- Which of the following is a serious complication of herpes zoster?
- Pneumonia
- Postherpetic neuralgia
- Meningitis
- Hepatitis
Answer:
B. Postherpetic neuralgia
Feedback: Postherpetic neuralgia (PHN) is the most common and clinically significant complication of herpes zoster, particularly in older adults. It results from nerve damage caused by viral inflammation and can persist for months to years. While other options listed may occur rarely or in specific populations, PHN represents the greatest long-term morbidity risk and is a primary reason for early antiviral intervention.
- Which part of the immune system is primarily responsible for controlling VZV reactivation?
- Humoral immunity
- Adaptive immunity
- Innate immunity
- Complement system
Answer:
B. Adaptive immunity
Feedback: Cell-mediated adaptive immunity—particularly T-cell–mediated responses—is essential for maintaining suppression of latent VZV. Declines in adaptive immunity due to aging, stress, or immunosuppression increase the risk of viral reactivation. Humoral and innate immunity play supportive roles but are not the primary controllers of latency.
- What is the characteristic pattern of the rash in herpes zoster?
- Bilateral and symmetrical
- Unilateral and dermatomal
- Diffuse and scattered
- Central and localized
Answer:
B. Unilateral and dermatomal
Feedback: Herpes zoster classically presents as a unilateral vesicular eruption limited to a single dermatome, reflecting viral spread along a specific sensory nerve. Bilateral or diffuse patterns should prompt consideration of alternative diagnoses or disseminated infection, particularly in immunocompromised patients.
- Which of the following is NOT a typical symptom of herpes zoster?
- Severe pain
- Vesicular rash
- Coffee colored patches on the skin
- Headache
Answer:
C. Coffee colored patches on the skin
Feedback: Herpes zoster typically presents with pain, vesicular rash, and flu like symptoms such as headache or fatigue. Coffee-colored skin patches are not characteristic of VZV infection.
- Which of the following statements best describes the appropriate timing for initiating antiviral therapy for herpes zoster?
- Within 24 hours of rash onset.
- Within 72 hours of rash onset.
- Within 5 days of rash onset.
- Only after the rash has fully developed.
Answer:
B. Within 72 hours of rash onset.
Feedback: Antiviral therapy is most effective when initiated within 72 hours of rash onset, when viral replication is most active. Early treatment significantly reduces symptom duration and the risk of postherpetic neuralgia. Treatment may still be considered beyond 72 hours in patients with ongoing lesion formation or high-risk features, but early initiation remains the standard of care.
- A patient with herpes zoster asks about the risk of spreading the infection to others. As a nurse practitioner, which of the following is the most appropriate response?
- Herpes zoster is not contagious.
- Direct contact with the rash can transmit varicella to susceptible individuals.
- Most people with shingles get the virus from their grandchildren who have chickenpox .
- Once the rash has crusted over, there is no risk of transmission.
Answer:
B. Direct contact with the rash can transmit varicella to susceptible individuals.
Feedback: While herpes zoster itself is not spread person-to-person, direct contact with vesicular fluid can transmit VZV to individuals who have never had chickenpox or the varicella vaccine, resulting in primary varicella infection.
- A 55-year-old patient recovering from herpes zoster asks about preventing future outbreaks. As a nurse practitioner, what is the most appropriate recommendation?
- Annual blood tests to check for virus reactivation
- Prophylactic antiviral therapy for life
- Vaccination with the herpes zoster vaccine (Shingrix)
- Avoiding stress and maintaining a healthy lifestyle
Answer:
C. Vaccination with the herpes zoster vaccine (Shingrix)
Feedback: Shingrix is the most effective intervention for preventing herpes zoster recurrence and its complications, including PHN. Vaccination is recommended even after a prior shingles episode and provides durable protection by enhancing VZV-specific cellular immunity.
References
Centers for Disease Control and Prevention. (2024). Shingles vaccine recommendations. Retrieved from https://www.cdc.gov/shingles/hcp/vaccine-considerations/index.html
Centers for Disease Control and Prevention. (2024). Shingles vaccination. Retrieved from https://www.cdc.gov/shingles/vaccines/index.html
Centers for Disease Control and Prevention. (n.d.). Clinical overview of shingles. (Herpes zoster). Retrieved February 22, 2025,, from https://www.cdc.gov/shingles/hcp/clinical-overview/?CDC_AAref_Val=https://www.cdc.gov/shingles/hcp/clinical-overview.html
Heavey, E. (2024). Lecture on the pathophysiology of Infectious Diseases. [Transcript].
Janniger, C. K. (2021, October 18). Herpes zoster clinical presentation. Medscape. https://emedicine.medscape.com/article/1132465-clinical
Mayo Clinic. (2024). Shingles vaccine. Retrieved from https://www.mayoclinic.org/diseases-conditions/shingles/expert-answers/shingles-vaccine/faq-20057859
MedlinePlus. (2021, September 16). Shingles. U.S. National Library of Medicine. https://medlineplus.gov/shingles.html
Microsoft. (2024). Copilot [AI assistant]. Microsoft Corporation.
Tkacs, N. (Ed.). (2020). Advanced physiology and pathophysiology: Essentials for clinical practice. Springer Publishing Company.
World Health Organization. (2022, May 16). Shingles (Herpes Zoster). https://www.who.int/news-room/fact-sheets/detail/shingles-(herpes-zoster)
You.com. (n.d.). Homepage. You.com. Retrieved February 22, 2025, from https://www.you.com
Media Attributions
- Herpes Zoster © NIAID is licensed under a CC BY (Attribution) license
.jpg){kind=link}