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My clinical experience this week was very informative.  I am beginning to feel more comfortable with performing assessments and discussing possible diagnoses with my preceptor.  The pace in the clinic is pretty quick, so I struggle with the fast patient turn-over and charting, but my preceptor has given me a lot of great tips that I hope I can carry on in the future when I become a nurse practitioner.I have also practiced some tips to promote mindfulness in my practice in order to avoid mistakes and becoming overwhelmed, such as deep breathing practices.

This week, a 27 year old female patient presented to the clinic complaining of a flare of her genital herpes.  Genital herpes presents with genital pain, vesicles, fever, malaise, regional adenopathy, and lesions in the cervix for some women (Arcangelo et al., 2016).  This condition is the most common genital ulcer disease, affecting roughly about 50 million individuals in the United States (Arcangelo et al., 2016).  Genital herpes is a viral infection with no cure, however it can be managed through pharmacologic treatment.  The first few episodes of genital herpes may be severe and require hospitalization, but many people are asymptomatic or unaware they have the infection, which is why herpes simplex virus (HSV) is the most common viral STI with 500 thousand new cases each year (Arcangelo et al., 2016).  Differential diagnoses for genital herpes with an infectious source includes conditions such as cancroid, fungal infections, granuloma inguinale, lymphogranuloma venereum, bacterial infections, and syphilis (Groves, 2016).Noninfectious conditions that are differential diagnoses include aphthous ulcers and Behçet syndrome (Groves, 2016).

A pharmacologic treatment plan for genital herpes includes an array of antivirals and symptomatic management through pain control and antipyretics.  Antivirals such as acyclovir, famciclovir, and valacyclovir inhibit DNA replication and are highly effective in managing these viral outbreaks (Arcangelo et al., 2016).  Antivirals should be initiated through a first, second, and third-line therapy basis.  First-line therapy includes use of acyclovir to treat the first outbreak of the virus.  Dosage of acyclovir for the initial outbreak includes 400 mg 3 times a day for 7-10 days or 200 mg 5 times a day for 7-10 days (Arcangelo et al., 2016).  Dosage of famciclovir for the initial outbreak should be 250 mg 3 times a day for 7-10 days (Arcangelo et al., 2016).  Dosage for valacyclovir for the initial outbreak should be 1 g 2 times a day for 7-10 days (Arcangelo et al., 2016).  Second-line therapy is aimed at treating recurrent episodes of the outbreak.  The dosages of second-line medications include acyclovir: 400 mg 3 times a day for 5 days, 800 mg two times a day for 5 days, or 800 mg 3 times a day for 2 days, or famciclovir: 125 mg 2 times a day for 5 days or 1 g 2 times a day for 1 day, and lastly valacyclovir: 500 mg 2 times a day for 3 days, or 1 g once a day for 5 days (Arcangelo et al., 2016).  Lastly, third-line therapy is aimed at suppressing the outbreaks.  This type of therapy is used for individuals with 6 or more outbreak episodes a year, and goal is to discontinue therapy after one year to determine need of continuing (Arcangelo et al., 2016).This may include a regimen of acyclovir 400 mg twice a day, famciclovir 250 mg twice a day, or valacyclovir 500 mg to 1 g once a day (Arcangelo et al., 2016).

While HSV cannot be cured, the outbreaks and symptoms can be managed.  The goal for pharmacologic management of this condition is to control symptoms of the outbreaks.  Monitoring the patient’s response to the drug therapy includes monitoring symptoms relief and resolution of lesions (Arcangelo et al., 2016).  This client had a known 6-year history of genital herpes and flares, so she was initiated on a regimen of acyclovir 400 mg 3 times a day for 5 days and will follow up with the clinic in approximately two weeks from her visit.She was also encouraged to refrain from any sexual activity until the outbreak recovers, manage pain relief with over-the-counter analgesics such as acetaminophen and ibuprofen, and perform sitz baths as needed for pain management.

References

Arcangelo, P. V., Peterson, M. A., Wilbur, V., & Reinhold, A. J. (2016). Pharmacotherapeutics for Advanced Practice: A Practical Approach (4th Ed.). Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins American. ISBN: 9781496319968

Groves, M. J. (2016). Genital herpes: a review. American family physician, 93(11), 928-934.