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CHIEF COMPLAINT: Possible shingles.
HISTORY OF PRESENT ILLNESS: Established patient is a 49 year-old female patient of Dr. who returns today for possible shingles. She said that she has felt pain on the right side for the past 3 days. She thought she was bitten by a bug. She had 1 small blister. Now she has 5 or 6 blisters in the area. She said she gets occasional jolts of electric-type pain in the right rib cage even away from where the blister area is extending to the right anterior thorax. She has a deep, burning, stinging sensation and it is uncomfortable to have her clothing rubbing this area. She says she has been little over stressed lately and has not been sleeping very well. She denies any fever though says her energy level has been low this week. No nausea, vomiting, diarrhea or chest pain. No other new complaints.
SOCIAL HISTORY: She does not smoke or drink alcohol.
PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 115.6, blood pressure 120/80, pulse 60, respirations 12, temp 97.1.
GENERAL: Well-appearing female in no acute distress.
SKIN: The patient has vesicular, papular lesions in a grouped area measuring approximately 1 x 2 cm over the right lateral thoracic area, tender to touch.
NECK: Supple, no masses, bruits or thyromegaly.
LUNGS: Clear to auscultation with equal expansion.
HEART: Regular rate and rhythm, S1, S2, no murmurs, rubs or gallops.
EXTREMITIES: No edema, pulses 2+ distally.
ASSESSMENT: Probable herpes zoster, right thoracic.
PLAN: 1. Famvir 500 t.i.d. x 7 days. 2. Lyrica 75 at night. 3. Notify for any progressive or persistent symptoms.
CHIEF COMPLAINT: Possible shingles.
HISTORY OF PRESENT ILLNESS: Established patient is a 49 year-old female patient of Dr. who returns today for possible shingles. She said that she has felt pain on the right side for the past 3 days. She thought she was bitten by a bug. She had 1 small blister. Now she has 5 or 6 blisters in the area. She said she gets occasional jolts of electric-type pain in the right rib cage even away from where the blister area is extending to the right anterior thorax. She has a deep, burning, stinging sensation and it is uncomfortable to have her clothing rubbing this area. She says she has been little over stressed lately and has not been sleeping very well. She denies any fever though says her energy level has been low this week. No nausea, vomiting, diarrhea or chest pain. No other new complaints.
SOCIAL HISTORY: She does not smoke or drink alcohol.
PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 115.6, blood pressure 120/80, pulse 60, respirations 12, temp 97.1.
GENERAL: Well-appearing female in no acute distress.
SKIN: The patient has vesicular, papular lesions in a grouped area measuring approximately 1 x 2 cm over the right lateral thoracic area, tender to touch.
NECK: Supple, no masses, bruits or thyromegaly.
LUNGS: Clear to auscultation with equal expansion.
HEART: Regular rate and rhythm, S1, S2, no murmurs, rubs or gallops.
EXTREMITIES: No edema, pulses 2+ distally.
ASSESSMENT: Probable herpes zoster, right thoracic.
PLAN: 1. Famvir 500 t.i.d. x 7 days. 2. Lyrica 75 at night. 3. Notify for any progressive or persistent symptoms.
