Chief complaint: rash x 2 days

HPI

73 y.o. F with PMH of poorly controlled DMII, HTN, HLD and osteoporosis presents c.o. rash on abdomen and back x 2 days. The pt states that she began feeling general weakness and malaise approximately one week ago, but has been busy caring for her grandchildren and attributed it to being tired and stressed. She states that the rash began 2 days ago as a red patch with a few blisters, but when she woke up this morning it was much worse prompting her visit today. She reports mild discomfort in the area of the rash that feels like a constant throbbing, is a 4/10, does not radiate and has no aggrevating or alleviating factors. The pt states that she has not taken anything for the rash and denies other areas affected by the rash. She denies fever, chills, N/V, abdominal pain, change in bowel habits, recent travel or known sick contacts. She reports that she has never received the herpes zoster vaccine.

PMH

• DMII
• HTN
• HLD
• Osteoporosis

PSH

None

Mediciations

• Lantus 100 UNIT/ML Solution 35 U Subcutaneous qhs with snack
• Metformin HCl 1000 MG Tablet 1 tablet with meals PO BID
• GlipiZIDE 5 MG Tablet 1 tablet PO qd
• Senna S 8.6-50 MG Tablet 1 tablet PO in the evening prn
• Ventolin HFA 108 (90 Base) MCG/ACT Aerosol Solution 2 puffs prn q4 hrs
• Oscal 500/200 D-3 500-200 MG-UNIT Tablet 1 tablet with food PO qd
• Carvedilol 25 MG Tablet 1 tab PO qd
• Losartan Potassium 100 MG Tablet 1 tablet PO qd
• Ecotrin Low Strength 81 MG Tablet Delayed Release 1 tablet PO qd
• Hydrochlorothiazide 12.5 MG Tablet 1 tablet PO qd
• Amlodipine Besylate 10 MG Tablet 1 tablet PO qd

Allergies

NKDA

FHX

Mother: DMII, deceased at 83

Father: HLD, HTN, deceased at 71

Daughter: alive and well

Daughter: alive and well

Son: DMII, alive and well

SHX

She is widowed and lives with her granddaughter. She retired from work in 2007 and cares for herself at home with occasional help from family members. She lives in a second floor walk-up apartment, denies recent travel, drug, alcohol, or cigarette use.

ROS

• Constitutional: negative for fever and chills, but admits some fatigue and general malaise
• HEENT:
• Eyes: no recent changes in vision, photophobia, or glasses use
• Ears: hearing intact
• Nose: no epistaxis or obstruction
• Mouth and throat: no ulceration, hx of candidiasis, denture use
• Neck: no lumps, localized swelling or stiffness
• Respiratory: No SOB, cough, wheezing, hemoptysis, PE, pneumonia, TB or TB exposure
• Cardiac: no recent CP, palpitations, edema of hands or feet, syncope, known murmur
• GI: denies abdominal pain, constipation, diarrhea, nausea or vomiting
• GU: admits urinary urgency and frequency but denies dysuria or hematuria
• Musculoskeletal: denies myalgias
• Skin: mildly painful rash extending from right mid abdomen to the middle of the right back
• Neurological: negative for headaches

PE

• VS: BP 142/78 left arm, sitting position; pulse 75 regular; O₂ sat 98% room air; respirations 17/min; temp 97.8°F oral; weight 162lbs; BMI 26.96
• Patient is alert and oriented x 3, appears well-developed and nourished in no apparent distress
• HEENT: normocephalic atraumatic, PERRLA, EOMI, face symmetric, oropharynx clear and moist
• Neck: FROM, trachea midline, no palpable cervical adenopathy
• Heart: RRR, no heaves, gallops, murmurs
• Lungs: equal breath sounds b/l, no wheezing/rales, no retractions or accessory muscle use
• Abdomen: soft, nontender, bowel sound active, no distention, no CVA tenderness
• Extremities: no deformities or injuries, distal pulses intact
• Skin: severe bullous vesicular rash on erythematous base along right side T10-T11 dermatome that does not cross the midline, no purulence or warmth noted
• Neuro: age appropriate neuro exam, no focal neurological deficits, CN III-XII grossly intact 

Labs

• CMP: Chloride 91; Sodium 128; Creatinine 1.05; Glucose 486; EGFR 50
• HGB A1C: 11.1
• Urinalysis: Glucose, urine 3+>= 1000mg/dL; leukocyte esterase small; WBC, urine 5-10
• ESR: 53

DDx

• Herpes zoster
• Hypersensitivity reaction
• Atopic dermatitis

Assessment: 73 y.o. F with PMH as stated above presenting with mild discomfort and vesicular rash in dermatomal pattern that does not cross midline consistent with herpes zoster.

Plan

• Order labs (CBC, CMP, HGB A1C, Rheumatology panel)
• Cephalexin 500 MG Tablet 1 tablet PO q 12 hrs
• Gabapentin 100 MG Capsule 1 capsule PO TID
• Acyclovir 800 MG Tablet 1 tablet PO TID
• Mupirocin 2 % Ointment 1 application to affected area Externally TID
• Follow up in 1 week