SOAP Note # _____
\nMain Diagnosis: Herpes Zoster<\/p>\n
PATIENT INFORMATION:
\nName: Ms. GP
\nAge: 78
\nGender at Birth: Female
\nGender Identity: Female
\nSource: Patient
\nAllergies: Peanut, Iodine
\nCurrent Medications:<\/p>\n
Insulin Lantus 100 u\/ml 15 unit in the morning and at bedtime
\nMetformin 500 mg 1 tablet PO once a day
\nAtorvastatin 20 mg 1 tablet PO at bedtime
\nPMH:
\nDiabetes mellitus type II
\nHyperlipidemia
\nVaricella (Chickenpox) at the age of 20 years old
\nImmunizations: Flu vaccine in 2020, Covid-19 (Pfizer) in 2021
\nPreventive Care: Wellness exam on 03\/2021
\nSurgical History: Appendicectomy 20 years ago
\nFamily History: Daughter (48 years old) with hyperlipidemia
\nSocial History: Patient is a widow and lives with her daughter. She is of Catholic religion, does not consume alcohol, does not smoke, has no history of drug use, and leads a sedentary lifestyle. She does not work.
\nSexual Orientation: Straight
\nNutrition History: Regular diet, low in carbohydrates and fat.
\nSUBJECTIVE DATA:
\nChief Complaint: “I have been feeling itching and pain on my right lower back” for the past 3 days.
\nSymptom analysis\/HPI: Ms. GP is a 78-year-old Hispanic female who is experiencing an increase in itching, pain, and tingling on her right lower back that started 3 days ago. She states that wearing clothes that touch the area is very uncomfortable and analgesics have not relieved the pain. She denies having a fever but reports experiencing fatigue, chills, and a mild headache. She notes that the area appears redder today and decided to come to the clinic for evaluation.<\/p>\n
REVIEW OF SYSTEMS (ROS):
\nCONSTITUTIONAL: Fatigue, chills, denies weakness, no thirst, no weight loss. No fever.
\nNEUROLOGIC: Mild headache, no dizziness, no changes in LOC, no weakness\/paresis\/paralysis on extremities, no history of tremors or seizures.
\nHEENT: Denies any head injury, denies any pain.<\/p>\n
Eyes: Denies blurred vision, no diplopia, wears glasses for reading.
\nEars: Denies tinnitus, ear pain, no ear drainage through ear canal.
\nNose: No nasal obstruction, no nasal discharge, no nasal bleeding (no epistaxis).
\nThroat: No sore throat, no hoarse voice, no difficulty swallowing.
\nRESPIRATORY: Denies shortness of breath, cough, expectoration, or hemoptysis.
\nCARDIOVASCULAR: Denies chest pain, tachycardia, orthopnea, or paroxysmal nocturnal dyspnea.
\nGASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting, or diarrhea. Bowel movement pattern is every other day, last BM was today, and no rectal bleeding is visible for her.
\nGENITOURINARY: Denies polyuria, dysuria, burning urination, hematuria, lumbar pain, or urinary incontinence.
\nMUSCULOSKELETAL: Denies falls or pain. Den INTEGUMENTARY: painful redness rash, with crops of vesicles on an erythematous base
\nwith a few satellite lesions in linear distribution, do not cross midline, some of the blisters are
\nfilled with purulent fluids and other are crusted. Area is swollen and redness.
\nASSESSMENT:
\nPatient Ms. GP is 78-year-old Hispanic woman with Hx of DM Type II and Hyperlipidemia,
\ncame into our clinic today complaining about itching, pain and tingling on her right lower back
\nstarting 3 days ago. During the physical exam was noted painful redness rash, with crops of
\nvesicles on an erythematous base with a few satellite lesions in linear distribution, which do not
\ncross midline. Diagnosis is based on the clinical evaluation through history and physical
\nexamination. According to patient presentation, signs and symptoms patient is diagnosed with
\nherpes zoster. Patients falls into the high risk group based on Buttaro (2017). Herpes zoster is
\nviral infection that occurs with reactivation of the varicella-zoster virus and the patient referred
\nhas history of Chickenpox when she was 20 years old.
\nMain Diagnosis
\nHerpes Zoster (ICD10 B02.9): Herpes zoster is infection that results when varicella-zoster virus
\nreactivates from its latent state in a posterior dorsal root ganglion. Symptoms usually begin with
\npain along the affected dermatome, followed within 2 to 3 days by a vesicular eruption that is
\nusually diagnostic. (Domino, Baldor, Golding, &Stephens,2017).
\nOther diagnosis:
\nDiabetes mellitus type II. (ICD-10 E11.9)
\nHyperlipidemia. (ICD-10 E78.5)
\nDifferential diagnosis
\n\uf0b7 Irritant contact dermatitis (ICD10 L24)
\n\uf0b7 Impetigo. (ICD10 L01.0)
\n\uf0b7 Varicella. (ICD 10 B01)
\n\uf0b7 Dermatitis herpetiformis. (ICD10 L13.0)
\nPLAN:
\nLabs and Diagnostic Test to be ordered (if applicable)
\n\uf0b7 Viral culture, polymerase chain reaction for VZV
\nPharmacological treatment:
\n\uf0b7 Valtrex 1 gm TID x 7 days ideally during the prodrome, and is less likely to be effective if
\ngiven > 72 hours after skin lesions appear,
\n\uf0b7 VZV vaccine
\n\uf0b7 Pain-reliever NSAIDs
\n\uf0b7 Management of post herpetic neuralgia (Treatments include gabapentin, pregabalin)
\nContinue with current medication for chronic condition:
\n\uf0b7 Insulin Lantus 100 u\/ml 15 unit in the morning and at bedtime
\n\uf0b7 Metformin 500 mg 1 tablet PO once a day
\n\uf0b7 Atorvastatin 20 mg 1 tablet PO at bedtime
\nNon-Pharmacologic treatment:
\n\uf0b7 Do not scratch the area with dirty hands. Use lotion like calamine to refresh the area.
\n\uf0b7 Keep the area clean and dry.
\nEducation
\n\uf0b7 Isolation precaution \u2013 Type Contact
\n\uf0b7 Avoid contact with susceptible person like pregnancy woman, kids and
\nImmunocompromised patient.
\n\uf0b7 Education about hand washing.
\n\uf0b7 Avoid ABT cream.
\nFollow-ups\/Referrals
\nFollow up appointment 2 weeks \/ No referral needed at this time
\nCall if the symptoms are worse or you noticed any adverse reaction.
\nReferences
\nButtaro, T. M., Trybulski, J. A., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary care: a
\ncollaborative practice. St. Louis, MO: Elsevier.
\nDomino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017
\n(25th ed.). Print (The 5-Minute Consult Series).
\nMcCance, K. L., & Huether, S. E. (2019). Pathophysiology: the biologic basis for disease in
\nadults and children. St. Louis, MO: Elsevier.<\/p>\n","protected":false},"excerpt":{"rendered":"
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