Finger pain in a young man - Herpetic Whitlow

Summary:This case involves a middle-aged man presenting with finger pain, suspected to be caused by herpetic whitlow. The candidate was tasked with diagnosing the condition, understanding its impact on the patient's life, and formulating a management plan.

Key Points:

• History Taking:

  • Open-ended questions should be used to gather maximum information.

  • In this case, it was essential to ask about any history of cold sores or similar symptoms, as well as possible trauma.

  • Specific focus on the patient’s symptoms, such as sudden onset of finger pain, redness, and blistering.

• Differential Diagnosis:

  • Initial considerations included infection (paronychia, herpetic whitlow) and trauma.

  • The presence of cold sores pointed toward herpetic whitlow.

  • Rule out trauma or bacterial infections like staphylococcal paronychia.

• Management:

  • Clear explanation that popping the blister could worsen the condition by spreading the virus.

  • Antiviral treatment (acyclovir) is crucial to reduce viral replication.

  • Provide symptomatic relief, such as pain management, and offer advice on cold compresses.

• Communication Skills:

  • Ensure the patient understands the condition by explaining it step by step.

  • Avoid jargon, and check the patient’s understanding by asking follow-up questions.

  • Explain the risk of transmission and the importance of reducing contact, including the impact on sexual activity during active symptoms.

• Ethical Considerations:

  • Discuss sexual history sensitively, ensuring confidentiality and the patient’s comfort.

  • Proper patient consent for discussions and treatment should be maintained.

Important Considerations:

• Timely diagnosis is crucial to prevent complications.

• Herpetic whitlow can recur due to reactivation of the herpes virus, so educating the patient on potential triggers, such as stress or immunosuppression, is important.

• Clear communication regarding the chronic nature of herpes and precautions during outbreaks.

Diagnostic Approach:

1. Take a thorough history, focusing on recent trauma, infections, and cold sore history.

2. Examine the finger for characteristic signs like blisters, redness, and warmth.

3. Rule out bacterial infections and trauma through detailed questioning.

Management:

• Investigations:

  • Clinical diagnosis based on presentation; lab confirmation may include viral cultures or PCR.

• Treatment:

  • Antiviral therapy with acyclovir or valacyclovir.

  • Pain management with NSAIDs or paracetamol.

  • Cold compresses to alleviate local symptoms.

• Follow-up:

  • Reassess after treatment initiation.

  • Advise on the prevention of spread and recurrence management.

Communication Skills:

• Speak clearly and at a measured pace, avoiding long and complex sentences​.

• Engage the patient by breaking down the condition and treatment into manageable parts.

• Use empathy and active listening to ensure the patient feels supported​​.

Ethical Considerations:

• Confidential handling of sensitive discussions about sexual history.

• Encourage honest communication about the risk of viral transmission.

Additional Resources:

• General Medical Council’s "Good Medical Practice" for guidelines on communication and patient care​.

• Examiner feedback on PLAB2 stations, emphasizing real patient interaction, time management, and the importance of clarity in communication​​.