Herpes Zoster SOAP NOTE EXAMPLE 1

Herpes Zoster SOAP NOTE EXAMPLE 1

Soap Note # _____ Main Diagnosis: Dx: 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 year-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 / hyperlipidemia

Social History: Patient is widow, lives with her daughter. Catholic religion. No alcohol. No

smoker. No history of drug used, sedentary lifestyle. 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” started 3 day ago.

Symptom analysis/HPI: The patient is Ms. GP is 78-year-old Hispanic woman, who is complaining about itching, pain or tingling on her right lower back. Patient stated that 3 days ago she started to feel an increase in burning sensation on the area taking all right lower back and don’t relieve the pain with analgesic, she stated that wear any clothes that touch the area is very uncomfortable. Denies any episodes of fever but she feels fatigue and chills and mild headache.

She stated that today in the morning she feel worse and noted some redness in the area and decided to come to the clinic to PCP evaluation.

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CONSTITUTIONAL: fatigue, chills, denies weakness, no thirsty, no loss of weight. No fever.

NEUROLOGIC: mild headache, no dizziness, no changes in LOC, no loss of strength or

weakness/paresis/paralysis on extremities, no Hx of tremors or seizures.

HEENT: denies any head injury, denies any pain

 Eyes: patient denies blurred vision, no diplopia, no wear glasses for reading

 Ears: patient denies tinnitus, ear pain, no ear drainage through ear canal.

 Nose: no presence of nasal obstruction, no nasal discharge, denies nasal bleeding. (No epistaxis)

 Throat: no sore throat, no hoarse voice, no difficult to swallow

RESPIRATORY: patient denies shortness of breath, cough, expectoration, or hemoptysis.

CARDIOVASCULAR: patient denies chest pain, tachycardia. No orthopnea or paroxysmal nocturnal dyspnea.

GASTROINTESTINAL: patient denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhea. (BM pattern) every other day, last BM: today, no rectal bleeding visible for her.

GENITOURINARY: patient denies polyuria, no dysuria, no burning urination, no hematuria, no lumbar pain, no urinary incontinence.

MUSCULOSKELETAL: denies falls or pain. Denies hearing a clicking or snapping sound

SKIN: patient states itching, pain, or tingling sensation on her right lower back.

HEMO/LYMPH/ENDOCRINE: glands swelling on groin, denies bruising or abnormal

bleeding.

PSYCHIATRIST: patient denies anxiety, depression, denies hallucinations or delusions, no

mood changes

Objective Data:

VITAL SIGNS:

Temperature: 98.4 °F, Pulse: 82x ‘, BP: 122/71 mm hg, RR 19, PO2-97% on room air, Ht- 5’3”,

Wt 164 lb, BMI 30.2. Report pain 6/10.

GENERAL APPREARANCE: Adult, female. Alert and oriented x 3.

NEUROLOGIC: Alert, oriented to person, place, and time. Cranial nerves from I to XII intact.

Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5. Pupil

normal in size and equal. Deep tendon reflex presents.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no

tenderness.

 Eyes: No conjunctival injection, no icterus, visual acuity, and extraocular eye movements

intact. No nystagmus noted. Wear glasses.

 Ears: BL external canal pattern, permeable, no redness, no drainage, tympanic membrane

intact, pearly gray with sharp cone of light. No pain or edema noted.

 Nose: Nasal mucosa normal. No irritations.

 Mouth: oral mucosa pink, tongue central, papillaes normal distributed, no lesions

detected, present of upper and lower denture, fitting properly. Lips with no lesions.

 Neck: No lymphadenopathy noted. No jugular vein distention. No thyroid swelling or

masses, no thrills on auscultation.

CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary

refill < 2 sec. Peripheral pulses present and symmetric. No edema on BLE.

RESPIRATORY: Lungs sounds clear. Chest wall symmetric and no deformities, no intercostal

retractions, patient no noticed dyspnea, no orthopnea. No egophony, no pectoriloquy, no fremitus

or sign of condensation tissue on palpation. Resonance equal in both hemithorax. Lungs: breath

sounds present and clear on auscultation, no rales, no wheezing, no rhonchi.

GASTROINTESTINAL: Abdomen soft and non-tender. Continent to BB. Bowel sounds

present in all four quadrants; no bruits present over aortic or renal arteries. Last BM today.

GENITOURINARY: Costovertebral angles non-tenders, kidneys no palpable. External

genitalia present, no enlargement, no tumors palpable. Groins area noted with redness.

MUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits, no stiffness.

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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 evaluation 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.

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