History

PMH- HTN, erectile dysfunction

PSH-none

Allergies- penicillin (anaphylaxis)

Medications- lisinopril, sildenafil

Back pain- started 3 days ago (2 days before rash); on right mid back, consistent, burning, aspirin barely helped (took one aspirin yesterday), no specific timing, 8/10 severity

Rash- unilateral on right mid back; yesterday it looked like erythematous papules but today it has erupted into vesicles

Reports fatigue, malaise,

Reports fever was 101 F yesterday

No new detergents, no irritants

No recent travel, no new medications;  normal BM (last one was last night)

Denies n/v/SOB/CP/ abdominal pain

Childhood illness- chicken pox age 5

Physical Exam (also indicates what procedures should be done)

General- Well-groomed and in distress. AOx3.

Skin- Vesicles on erythematous base in dermatomal pattern on right mid back.

Head- normocephalic, atraumatic. Hair texture and distribution wnl.

Eyes- PERRL, EOMI, conjunctiva clear, red reflex intact

Ears- Canals clear, TM’s and pinna wnl.

Nose- septum and turbinates wnl. No discharge or deformities.

Mouth/ Throat- Pharynx/ tonsils/ uvula/soft palate/ tongue/gums wnl

Neck- supple, trachea midline. Thyroid wnl.

Nodes- cervical/ epitrochlear/ axillary/femoral wnl..

Thorax- lungs CTA. No retractions or accessory muscle use

Heart- RRR. No murmurs. S1 and S2 normal. No gallops/murmurs/rubs.

Breasts- Symmetrical. No masses/ dimples/discharge

Abdomen- soft, nontender, nondistended. BS present in all 4 quadrants. No hepatosplenomegaly, hernias, CVA tenderness

Extremities- full ROM, normal muscle tone and strength, no clubbing/ cyanosis

Back/ spine- straight with full ROM. No tenderness.

Genitalia- Normal external genitalia. No masses/ rashes/ lesions/ discharge.

Rectal- wnl. No fissures/ lesions/ rashes/ trauma

Neuro- A&O, CN II-XII intact, normal reflexes, sensory wnl

Psych- mood/ affect/ memory/ judgement wnl

Differential Diagnosis

o Herpes Zoster- rash in a dermatomal pattern; consistent with prodromal back pain

o Contact dermatitis – vesicular rash, however inconsistent with dermatomal pattern

o Drug allergy- often manifests dermatologically, unlikely because dermatomal pattern

Tests

Clinical diagnosis- consistent with Herpes Zoster

If you want to confirm- PCR VZV DNA positive (optional because can make a clinical diagnosis)

Treatment

Valacyclovir 1000 mg TID x 7 days (must be given within 72 hours of symptoms)

Pt. counseling

•  Inform pt that he is no longer contagious when vesicles crust over- keep it covered and wash hands often. Stay away from unvaccinated pregnant women, premature neonates, and immunocompromised people.
• NSAIDs for pain, Morphine ER prn (15 mg PO q8-12 hours as needed)
• Should get Zostavax upon recovery.