A 55-year-old male with a history of HTN and DM presents to the ED for a rash of 2-day duration. He reported mild URI symptoms for 4 days preceding the rash with myalgias and subjective fevers for which he has been taking naproxen. He notes the rash began as small painless, erythematous papules but has progressed to larger, tender bullae. The rash began on his trunk and has spread to his face and bilateral upper extremities. Vital signs include T 101.2F, BP 110/67, HR 109, RR 18, SpO2 of 99% on room air. On physical exam, a rash appears as shown below affecting approximately 20% of total body surface area (TBSA), and with gentle rubbing, skin sloughing is noted.

You are clerking a young boy and you notice that he has lots of visibly rotten teeth. You’re shocked as he is is only 4 years old. You ask his mother about his teeth and she says,
“We always brush his teeth every day” .
“He doesn’t really eat sweets”.
You ask if she has taken him to see the dentist and she replies, “We can’t find any dentists who are taking NHS patients at the moment”. This scenario is not unusual: around one-in-four 5-year-olds have dental decay, affecting, on average, three or four teeth. There is no substitute for seeing a dentist and getting a personal dental plan, but with a shortage of NHS dental appointments and the knock-on effects of COVID, it may be some time until the child is seen. This, added to the fact that children’s oral health has been found to deteriorate in hospitalised children, means that we should do more than advise a child to see a dentist.

A 79-year-old female with a history of heart failure, coronary artery disease, diabetes, and hypertension is brought in by family with worsening shortness of breath and peripheral edema over 8 days. She denies fevers, chest pain, abdominal pain, cough, and back pain. Her daughter accompanies her and states she has had multiple admissions for similar issues “When she doesn’t take her medications and eats a lot of soup.” She is overall well appearing and nontoxic, and her vital signs include BP 162/92 mm Hg, RR 19, HR 77, saturation 97% on room air, and T 97.4F. She has crackles at the bases of her lungs, and her legs demonstrate 2+ pitting edema.

Take Home Points:

• Fluorescein is an essential tool in the diagnosis of HSV keratitis
• Identifying the type of HSV keratitis is crucial, as it will guide treatment
• Update tetanus vaccination
• Consult ophthalmology if there is concern for HSV keratitis as these patients require close and frequent follow-up