Herpes Zoster Encounter at Miami Regional University
Student’s Name
Miami Regional University
Date of Encounter: Mo/day/year
Preceptor/Clinical Site: MSN5600L Class
Clinical Instructor: Patricio Bidart MSN, APRN-IP, FNP-C
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:
PMH:
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.
Review of Systems (ROS)
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
epistaxis)
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.
intact. No nystagmus noted. Wear glasses.
intact, pearly gray with sharp cone of light. No pain or edema noted.
detected, present of upper and lower denture, fitting properly. Lips with no lesions.
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.
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