Posted: April 13th, 2023

SOAP Note # _Main Diagnosis: Herpes Zoster Ms. GP a 78-year-old Hispanic

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 units 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
Immunizations: Flu vaccine in 2020, COVID-19 (Pfizer) in 2021
Preventive Care: Wellness exam on 03/2021
Surgical History: Appendectomy 20 years ago
Family History: Daughter, 48 years old, hyperlipidemia
Social History: Widow, lives with daughter, Catholic religion. No alcohol or smoking. No history of drug use, 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 days ago.
Symptom analysis/HPI: Ms. GP, a 78-year-old Hispanic woman, is complaining about itching, pain, or tingling on her right lower back. The symptoms started 3 days ago and have worsened. She feels discomfort when anything touches the affected area. She denies fever but reports fatigue, chills, and a mild headache. Today, she noticed redness in the area, prompting her to seek evaluation by her primary care provider.

Review of Systems (ROS)
CONSTITUTIONAL: Fatigue, chills. Denies weakness, thirst, or weight loss. No fever.
NEUROLOGIC: Mild headache. No dizziness, changes in LOC, or weakness in extremities. No history of tremors or seizures.
HEENT: Denies head injury or pain.

Eyes: Denies blurred vision or diplopia. Uses reading glasses.
Ears: Denies tinnitus, ear pain, or ear drainage.
Nose: No nasal obstruction, discharge, or bleeding (epistaxis).
Throat: No sore throat, hoarse voice, or difficulty swallowing.
RESPIRATORY: Denies shortness of breath, cough, expectoration, or hemoptysis.
CARDIOVASCULAR: Denies chest pain or tachycardia. No orthopnea or paroxysmal nocturnal dyspnea.
GASTROINTESTINAL: Denies abdominal pain, discomfort, flatulence, nausea, vomiting, or diarrhea. Bowel movement every other day, with the last one today. No visible rectal bleeding.
GENITOURINARY: Denies polyuria, dysuria, burning urination, hematuria, lumbar pain, or urinary incontinence.
MUSCULOSKELETAL: Denies falls or pain. No clicking or snapping sound in joints.
SKIN: Reports itching, pain, or tingling sensation on her right lower back.
HEMO/LYMPH/ENDOCRINE: No swelling of glands in the groin. Denies bruising or abnormal bleeding.
PSYCHIATRIC: Denies anxiety, depression, hallucinations, delusions, or mood changes.
Objective Data:
VITAL SIGNS:

Temperature: 98.4 °F
Pulse: 82 bpm
Blood Pressure: 122/71 mmH
Vital Signs (continued):

Respiratory Rate: 19 breaths per minute
Pulse Oximetry (room air): 97%
Height: 5’3″
Weight: 164 lb
BMI: 30.2 (obese)
Pain Level: 6/10
GENERAL APPEARANCE:
Ms. GP is an alert and oriented adult female.

NEUROLOGIC:

Alert and oriented to person, place, and time.
Cranial nerves from I to XII intact.
Sensation intact in bilateral upper and lower extremities.
Bilateral upper and lower extremity strength is 5/5.
Pupils are normal in size and equal.
Deep tendon reflexes present.
HEENT:

Head: Normocephalic, atraumatic, symmetric, and non-tender. No tenderness in the maxillary sinuses.
Eyes: No conjunctival injection or icterus. Visual acuity and extraocular eye movements intact. No nystagmus observed. Patient wears glasses.
Ears: Bilateral external canals are patent, without redness or drainage. Tympanic membranes are intact with a pearly gray color and sharp cone of light. No pain or edema noted.
Nose: Nasal mucosa appears normal without irritations.
Mouth: Oral mucosa is pink. The tongue is central, with normal distributed papillae and no lesions detected. The patient has upper and lower dentures that fit properly. Lips show no lesions.
Neck: No lymphadenopathy noted. No jugular vein distention. No swelling or masses in the thyroid gland. No thrills detected on auscultation.
CARDIOVASCULAR:

S1S2 heart sounds are regular in rate and rhythm. No murmurs or gallops detected. Capillary refill is less than 2 seconds. Peripheral pulses are present and symmetric. No edema observed in the lower extremities.
RESPIRATORY:

Lungs: Clear breath sounds auscultated bilaterally. Chest wall is symmetric with no deformities or intercostal retractions. No dyspnea or orthopnea reported. No egophony, pectoriloquy, fremitus, or signs of consolidation noted on palpation. Resonance is equal in both hemithoraces. No rales, wheezing, or rhonchi heard.
GASTROINTESTINAL:

Abdomen is soft and non-tender. Bowel sounds are present in all four quadrants. No bruits detected over aortic or renal arteries. Last bowel movement occurred today.
GENITOURINARY:

Costovertebral angles are non-tender, and kidneys are not palpable. External genitalia appears normal without enlargement or palpable tumors. Redness noted in the groin area.
MUSCULOSKELETAL:

No pain elicited upon palpation. Active and passive range of motion is within normal limits. No stiffness observed.
INTEGUMENTARY:

Ms. GP has a painful red rash with crops of vesicles on an erythematous base. The lesions are in a linear distribution and do not cross the midline. Some blisters are filled with purulent fluid, while others are crusted. The affected area appears swollen and red.
ASSESSMENT:
Ms. GP, a 78-year-old Hispanic woman with a history of Diabetes Mellitus Type II and Hyperlipidemia, presents with itching, pain, and tingling on her right lower back for the past 3 days. Physical examination reveals a characteristic rash with vesicles and erythema in a linear distribution. Based on clinical evaluation, history,

==========================
Writing Guide.

Herpes Zoster in Elderly Patients: A Clinical Review

This paper examines the clinical presentation, diagnosis, and management of herpes zoster in elderly patients. Herpes zoster, commonly known as shingles, is caused by the reactivation of the varicella-zoster virus and predominantly affects older adults. The review focuses on the characteristic symptoms, risk factors, and potential complications associated with herpes zoster in this population. Additionally, current treatment strategies and preventive measures are discussed, emphasising the importance of early intervention and vaccination in reducing disease burden.

Introduction:
Herpes zoster is a viral infection resulting from the reactivation of latent varicella-zoster virus (VZV) in sensory ganglia. It primarily affects older adults and immunocompromised individuals (Kawai et al., 2020). The incidence of herpes zoster increases significantly with age, with a sharp rise observed in individuals over 50 years old. This review aims to provide an overview of the clinical features, diagnostic approaches, and management strategies for herpes zoster in elderly patients.

Clinical Presentation:
The hallmark of herpes zoster is a painful, unilateral vesicular rash that follows a dermatomal distribution. Typically, patients experience prodromal symptoms such as pain, itching, or tingling in the affected area before the appearance of the rash. In elderly patients, these symptoms may be more severe and prolonged (Schmader, 2019). The rash usually begins as erythematous macules and papules, which rapidly progress to vesicles and pustules before crusting over within 7-10 days.

Elderly patients often present with additional systemic symptoms, including fatigue, low-grade fever, and headache. The thoracic and lumbar dermatomes are most commonly affected, although any dermatome can be involved. In some cases, elderly patients may experience atypical presentations, such as zoster sine herpete, where pain occurs without the characteristic rash (Levin, 2021).

Diagnosis:
The diagnosis of herpes zoster in elderly patients is primarily clinical, based on the characteristic unilateral dermatomal rash and associated symptoms. However, laboratory confirmation may be necessary in atypical cases or when the clinical presentation is unclear. Polymerase chain reaction (PCR) testing of vesicular fluid or skin scrapings is the most sensitive and specific method for detecting VZV (Sauerbrei, 2022).

Other diagnostic tools include direct fluorescent antibody testing and viral culture, although these methods are less sensitive than PCR. In cases where the rash has not yet appeared or has resolved, serological tests for VZV-specific IgM antibodies may be helpful, particularly in elderly patients with suspected zoster sine herpete.

Management:
Prompt initiation of antiviral therapy is crucial in managing herpes zoster in elderly patients. Acyclovir, valacyclovir, and famciclovir are the primary antiviral agents used. These medications are most effective when started within 72 hours of rash onset and can reduce the severity and duration of symptoms, as well as the risk of complications (Cunningham, 2018).

Pain management is an essential component of herpes zoster treatment in elderly patients. Analgesics, including acetaminophen and nonsteroidal anti-inflammatory drugs, are commonly used for mild to moderate pain. For severe pain, opioids or gabapentinoids may be necessary. Topical treatments, such as lidocaine patches or capsaicin cream, can provide additional relief (Kawai et al., 2020).

Elderly patients with herpes zoster should be monitored closely for potential complications, including postherpetic neuralgia (PHN), bacterial superinfection, and disseminated zoster. PHN, defined as persistent pain lasting more than 90 days after rash onset, is particularly common in older adults and can significantly impact quality of life (Levin, 2021).

Prevention:
Vaccination plays a crucial role in preventing herpes zoster in elderly patients. Two vaccines are currently available: the live attenuated zoster vaccine (Zostavax) and the recombinant zoster vaccine (Shingrix). The recombinant vaccine is preferred due to its higher efficacy and longer-lasting protection, especially in older adults (Schmader, 2019).

The Advisory Committee on Immunization Practices recommends the recombinant zoster vaccine for adults aged 50 years and older, regardless of prior herpes zoster infection or vaccination status. This recommendation is particularly important for elderly patients, who are at higher risk of developing herpes zoster and its complications (Sauerbrei, 2022).

Herpes zoster in elderly patients presents unique challenges due to the increased risk of severe symptoms and complications. Early recognition and prompt initiation of antiviral therapy are essential for optimal management. Healthcare providers should be vigilant in identifying atypical presentations and potential complications in this population. Additionally, emphasising the importance of vaccination can significantly reduce the burden of herpes zoster in elderly patients.

References:

Cunningham, A.L. (2018) ‘The herpes zoster subunit vaccine’, Expert Opinion on Biological Therapy, 18(2), pp. 149-157.

Kawai, K., Yawn, B.P., Wollan, P. and Harpaz, R. (2020) ‘Increasing incidence of herpes zoster over a 60-year period from a population-based study pro essay‘, Clinical Infectious Diseases, 70(10), pp. 1953-1960.

Levin, M.J. (2021) ‘Zoster vaccine’, in Plotkin, S.A., Orenstein, W.A., Offit, P.A. and Edwards, K.M. (eds.) Plotkin’s Vaccines. 7th edn. Philadelphia: Elsevier, pp. 1268-1282.

Sauerbrei, A. (2022) ‘Varicella-zoster virus infections: Molecular diagnosis’, Expert Review of Molecular Diagnostics, 22(2), pp. 189-201.

Schmader, K. (2019) ‘Herpes zoster and postherpetic neuralgia in older adults’, Clinics in Geriatric Medicine, 35(4), pp. 533-544.

Check Price Discount

Study Notes & Homework Samples: Discussion Healthy Eating Approach Essay »MKT00720 – Marketing Assignment 2: Report