Shellie Ray CRNP - Home



Shellie RayGeriatric SOAP NoteSUBJECTIVE:CHIEF COMPLAINT: “I have a rash on my back and side that is killing me.”HISTORY OF PRESENT ILLNESS: 69 yo wm presents to clinic with a unilateral rash on his right side extending around to his back. States he had been having a burning, throbbing pain especially with touch in this area over the past 48 hours and woke up this morning with the rash. The pain was worse at night and has some relief with ibuprofen. He has not been febrile.PMH: HTN, Dyslipidemia, GoutSx: appendectomy 1977, T & A 1965, ORIF of wrist after automobile wreck 1989Allergies: PCN causes rashMedications: Zestoretic 20/12.5 mg PO QD, ASA 81 mg PO QD, Ibuprofen 800 mg PO Q 6 hrs. PRN painAge/health status: 69 yom appearing to be in a good present state of healthPrevious Health Screening: Full physical in June with screening for diabetes and PSA, lipid profile. Colonoscopy scheduled Oct. 29, 2012Immunizations: Tetanus 2005, Flu Sept. 2012, Pneumonia 2008, Zostavax neverFAMILY HISTORY:Father: not living, Hypercholesterolemia, HTN, CAD, CataractsMother: not living, HTN, Depression, Breast cancer, COPDSisters X2: CAD, DM, HTNDaughter: healthySOCIAL HISTORY: Married for 45 years, lives with wife. One daughter who is married with a child. Retired high school principle. Masters degree education. Enjoys an occasional cigar, drinks one glass of red wine with dinner. Denies drug use. Sexual activity: monogamous relationship with wife, no birth control since his wife went through natural menopause 15 years ago. REVIEW OF SYSTEMS:Constitutionals: Denies fever, change in weight or fatigue. Positive for difficulty sleeping last night due to pain. Musculoskeletal: Positive right side and back pain. History of gout and ORIF of wrist. Denies arthritis.Cardiovascular: Denies chest pain, palpitations, dyspnea, orthopnea, edema. Denies varicose veins, claudication or history of DVT. Does not exercise. Positive for dyslipidemia and HTN. Respiratory: Denies cough, sputum, hemoptysis, dyspnea, wheezing, pleurisy, unknown last chest x-ray. Denies history of asthma, bronchitis, emphysema, pneumonia or tuberculosis. Denies exposure to tuberculosis and last PPD unknown. Positive for occasional cigar smoking.Integumentary: Pt denies eczema, psoriasis, skin infections. Positive for rash with lesions. Has several moles which he watches for changes. Fair skin and denies use of sunscreen. Objective:Height: 72 in. Weight: 195 BMI: 26.4Vital Signs: T 98.2 P 71 R 18 BP 136/89 Constitutionals: Pleasant, appropriately dressed and groomed adult male. Alert and orientated to person, place and time and answers all questions appropriately.HEENT: Head: receeding hairline, no presence of nits or lice, no lesions. Normocephalic. Eyes: Visual fields full by confrontation. Conjunctiva pink, sclera white. EOM intact, PERRLA, Ears: TM with good cone of light, ears without pain, redness, drainage, wax present. Nose: mucosa pink, septum midline. No sinus tenderness. Mouth: normal dentition. No presence of thrush or lesions. Tongue midline, pharynx without exudate.Cardiovascular: S1, S2 no S3 or S4. No gallops or murmurs. No presence of JVD. No carotid bruits. Calves are nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis and posterior tibial pulses are 2+ and symmetric.Respiratory: Clear to auscultation bilaterally, no rales, wheezes or rhonchi. Thorax symmetric with good excursion. Integument/Lymphatic: Skin to right side of thorax and back erythematous, with a unilateral, pruritic, vesicular skin rash. Does not cross midline.ASSESSMENT:Differential Diagnosis:Herpes zosterHerpes simplexVaricellaPoison ivyContact dermatitisDiagnosis: Herpes zoster ICD 9- 053PLAN: Acyclovir 800 mg PO 5 times a day for 7 days.Tylenol or Ibuprofen as needed for pain.Hydroxyzine 25 mg Po 3-4 times daily for itching. Calamine lotion as needed for itching.Patient education: The shingles rash usually lasts 2-3 weeks, however symptoms may persist beyond this period. Avoid contact with anyone who has not had the chickenpox or any pregnant woman. Avoid touching the lesions. Wash hands frequently. Return to clinic if symptoms worsen or pain uncontrolled with Ibuprofen or Tylenol as you may need something different for pain. Notify clinic immediately if lesions appear on face, especially around eye area. ReferencesCash J C Glass C A 2011 Family practice guidelinesCash, J. C., & Glass, C. A. (2011). Family practice guidelines (2nd ed.). New York, NY: Springer Publishing Company. Dunphy L M Winland-Brown J E Porter B O Thomas D J 2011 Primary care: the art and science of advanced practice nursingDunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary care: the art and science of advanced practice nursing (3rd ed.). Philadelphia, PA: F.A. Davis Company. 2012082821040868339467020120828210601934854742012082821060193485474 ................
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