SOAP Note # _____
Main Diagnosis: Herpes Zoster
PATIENT INFORMATION:
Name: Ms. GP
Age: 78
Gender at Birth: Female
Gender Identity: Female
Source: Patient
Allergies: Peanut, Iodine
Current Medications:
Insulin Lantus 100 u/ml 15 unit in the morning and at bedtime
Metformin 500 mg 1 tablet PO once a day
Atorvastatin 20 mg 1 tablet PO at bedtime
PMH:
Diabetes mellitus type II
Hyperlipidemia
Varicella (Chickenpox) at the age of 20 years old
Immunizations: Flu vaccine in 2020, Covid-19 (Pfizer) in 2021
Preventive Care: Wellness exam on 03/2021
Surgical History: Appendicectomy 20 years ago
Family History: Daughter (48 years old) with hyperlipidemia
Social 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.
Sexual Orientation: Straight
Nutrition History: Regular diet, low in carbohydrates and fat.
SUBJECTIVE DATA:
Chief Complaint: “I have been feeling itching and pain on my right lower back” for the past 3 days.
Symptom 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 Assessment.
REVIEW OF SYSTEMS (ROS):
CONSTITUTIONAL: Fatigue, chills, denies weakness, no thirst, no weight loss. No fever.
NEUROLOGIC: Mild headache, no dizziness, no changes in LOC, no weakness/paresis/paralysis on extremities, no history of tremors or seizures.
HEENT: Denies any head injury, denies any pain.
Eyes: Denies blurred vision, no diplopia, wears glasses for reading.
Ears: Denies tinnitus, ear pain, no ear drainage through ear canal.
Nose: No nasal obstruction, no nasal discharge, no nasal bleeding (no epistaxis).
Throat: No sore throat, no hoarse voice, no difficulty swallowing.
RESPIRATORY: Denies shortness of breath, cough, expectoration, or hemoptysis.
CARDIOVASCULAR: Denies chest pain, tachycardia, orthopnea, or paroxysmal nocturnal dyspnea.
GASTROINTESTINAL: 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.
GENITOURINARY: Denies polyuria, dysuria, burning urination, hematuria, lumbar pain, or urinary incontinence.
MUSCULOSKELETAL: Denies falls or pain. Den INTEGUMENTARY: painful redness rash, with crops of vesicles on an erythematous base
with a few satellite lesions in linear distribution, do not cross midline, some of the blisters are
filled with purulent fluids and other are crusted. Area is swollen and redness.
ASSESSMENT:
Patient Ms. GP is 78-year-old Hispanic woman with Hx of DM Type II and Hyperlipidemia,
came into our clinic today complaining about itching, pain and tingling on her right lower back
starting 3 days ago. During the physical exam was noted painful redness rash, with crops of
vesicles on an erythematous base with a few satellite lesions in linear distribution, which do not
cross midline. Diagnosis is based on the clinical Assessment through history and physical
examination. According to patient presentation, signs and symptoms patient is diagnosed with
herpes zoster. Patients falls into the high risk group based on Buttaro (2017). Herpes zoster is
viral infection that occurs with reactivation of the varicella-zoster virus and the patient referred
has history of Chickenpox when she was 20 years old.
Main Diagnosis
Herpes Zoster (ICD10 B02.9): Herpes zoster is infection that results when varicella-zoster virus
reactivates from its latent state in a posterior dorsal root ganglion. Symptoms usually begin with
pain along the affected dermatome, followed within 2 to 3 days by a vesicular eruption that is
usually diagnostic. (Domino, Baldor, Golding, &Stephens,2017).
Other diagnosis:
Diabetes mellitus type II. (ICD-10 E11.9)
Hyperlipidemia. (ICD-10 E78.5)
Differential diagnosis
Irritant contact dermatitis (ICD10 L24)
Impetigo. (ICD10 L01.0)
Varicella. (ICD 10 B01)
Dermatitis herpetiformis. (ICD10 L13.0)
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
Viral culture, polymerase chain reaction for VZV
Pharmacological treatment:
Valtrex 1 gm TID x 7 days ideally during the prodrome, and is less likely to be effective if
given > 72 hours after skin lesions appear,
VZV vaccine
Pain-reliever NSAIDs
Management of post herpetic neuralgia (Treatments include gabapentin, pregabalin)
Continue with current medication for chronic condition:
Insulin Lantus 100 u/ml 15 unit in the morning and at bedtime
Metformin 500 mg 1 tablet PO once a day
Atorvastatin 20 mg 1 tablet PO at bedtime
Non-Pharmacologic treatment:
Do not scratch the area with dirty hands. Use lotion like calamine to refresh the area.
Keep the area clean and dry.
Education
Isolation precaution – Type Contact
Avoid contact with susceptible person like pregnancy woman, kids and
Immunocompromised patient.
Education about hand washing.
Avoid ABT cream.
Follow-ups/Referrals
Follow up appointment 2 weeks / No referral needed at this time
Call if the symptoms are worse or you noticed any adverse reaction.
References
Buttaro, T. M., Trybulski, J. A., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary care: a
collaborative practice. St. Louis, MO: Elsevier.
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017
(25th ed.). Print (The 5-Minute Consult Series).
McCance, K. L., & Huether, S. E. (2019). Pathophysiology: the biologic basis for disease in
adults and children. St. Louis, MO: Elsevier.
