Overall very well done.  Good capture of information.  HPI well sequenced and concise.  Few minor issues with Hx and PE – see my comments below.  When describing a skin lesion/eruption, need to be precise about its location/distribution – using landmarks (or in this case, note that it follows the distribution of the V₁)

Identifying Data:

Name: IM

Sex: Female

Address: New York

Age: 72 y/o

Date & Time:

Location: Metropolitan Geriatric Clinic

Marital Status: Widowed 

Religion: Christian

Race: Hispanic

Source of Information: Self and Son

Reliability: Reliable

Mode of Transport: Public Transportation

Chief Complaint: “My eye is still really hurting me” x14 days

History of Present Illness:

IM is a 72 year old reliable female with a past medical history of HTN, HLD, vitamin D deficiency, living alone, ambulatory with no assisted devices and independent in ADLs, presented to the emergency room two weeks ago for pain, itchiness and redness in her left eye. The pain began upon waking up in the morning. The pain was rated a 7/10 and was characterized by the patient as a sharp constant pain. The pain did not radiate anywhere. The patient admitted to slight photophobia, but had no change in visual acuity. Her extraocular ocular movements were all present and had PERLL. Patient admits to tearing of the eye and a slight upper left sided headache. Patient denies wearing contacts or glasses. Patient denied nasal discharge, bilateral symptoms, and being in contact with anyone who is sick. The rest of the ROS was negative and she was discharged home with a diagnosis of conjunctivitis with Ciprofloxacin 0.3% ophthalmic solutions. Good summary of the previous visit, setting the stage for this current one.

Patient arrived to the clinic this morning due to worsening of the redness and eye pain in her left eye. Patient is unable to currently open her left eye due to intense pain and pressure in the left eye. IM has developed a painful skin rash over the left side of her face that does not affect the right side of her face. Patient rates the rash a 7/10. Pain does not radiate anywhere. Patient feels a generalized heaviness of the face due to the pain. Patient admits that her left eye is constantly tearing and that she has had decreased vision over the last four days. IM also admits to photophobia and once again denies contact with anyone who has been sick recently. Patient also denies any recent travel.

Would like to document at least asking about history of varicella and Shingrix (or earlier vaccine – Zostavax which was approved in 2006)

Geriatric Assessment

ADLs: independent in all

IADLS: Needs assistance in meal preparation, household chores, transportation, communication, paying bills and shopping

Visual Impairment: Yes – left eye unable to see or open

Hearing impairment: None

Falls in the past year: None

Assistive devices used: None

Gait Impairment: Yes- slightly unsteady for how long

Urinary incontinence: None

Fecal incontinence: None

Osteoporosis: None

Cognitive Impairment: None (Mini-Cog not done today because patient is acutely ill)  Any earlier result on chart?

Depression: None

Home safety issues: None

Health Care Proxy: Yes – son

Advance directives: full code

Follow up in one week with medications.

Past Medical History:

Present medical illnesses – HTN, HLD, Vitamin D deficiency

Childhood illnesses – none

Immunizations – Up to date with the flu vaccine and the TDAP vaccine. Due for the COVID vaccine, second dose of Shingrix, PPSV23.

Past Surgical History:

Denies any past surgical history

Medications:

Aspirin 81 mg PO once daily

Cholecalciferol, 1000 units, PO once daily

Ezetimibe 10 mg tablet PO once daily

Lisinopril-hydrochlorothiazide 20-25 mg PO once daily

Ciprofloxacin 0.3% ophthalmic solutions; administer 1 drop into the left eye 4 times a day.

Allergies:

Allergic to Penicillin, will have a rash if she takes it.

No known food, or environmental allergies.

Family History:

Need some statement as to why you’ve reported none

Social History:

IM is living in the fourth floor of a 6^th floor apartment building alone (elevator? Any stairs?). She denies the past or present use of alcohol, cigarettes, tobacco, or and illicit drugs. She drinks one cup of coffee each day. Patient receives 5-6 hours of sleep each night. Patient does not exercise and has a diet that consists of many fast food take out dinners. IM is currently not sexually active but has always had male partners. Denies any history of STDs.

Review of Systems:

General – Admits to headache. Denies fever, loss of appetite, recent weight gain or loss, generalized weakness/fatigue, or night sweats.

Skin, hair, nails –Admits to facial skin rash around the left eye, the left forehead, and left upper scalp. Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Admits to headache. Denies dizziness, vertigo or head trauma, head fracture or coma.

Eyes –  Admits to left eye visual disturbance, photophobia, eye pain, pruritus, and tearing. Denies contacts or glasses. Last eye exam x3 year ago- normal.

Ears –Denies deafness, tinnitus, pain, discharge, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat – Denies bleeding gums, denies dentures, sore throat, sore tongue, mouth ulcers, voice changes. Last dental exam x4years – normal. 

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion.

Breast- Denies lumps, nipple discharge, and pain.

Pulmonary– Denies dyspnea, DOE, cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis and hemoptysis.

Cardiovascular–Denies chest pain or shortness of breath. Denies swelling of the extremities, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal-  Denies flatulence, eructation, acid reflux and blood in the stool. Denies change in appetite, intolerance to specific foods, vomiting, nausea, constipation, dysphagia, pyrosis, abdominal pain, diarrhea, jaundice, hemorrhoids, rectal bleeding, or blood in stool.

Genitourinary system – Denies urinary frequency, urgency, slight incontinence and nocturia. Denies oliguria, polyuria, dysuria, or flank pain.

Sexual History-  Patient denies being currently sexually active. Partners were always male. Denies history of sexually transmitted diseases and impotence.

Nervous – Denies seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.

Musculoskeletal system – Denies deformity or swelling, redness or arthritis. Denies joint or muscle pain.

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

Hematological system – Denies anemia, easy bruising or bleeding. Denies lymph node enlargement, or history of DVT/PE.

Endocrine system –Denies polyuria, polyphagia, polydipsia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric – Admits to anxiety that has developed over the COVID-19 Pandemic. Has not seen any medical professional and has not taken any medication to help with her anxiety.

Physical Exam

General: 72  year old female, alert and oriented to person, place and time.  Patient appears to be distressed. Patient appears to be her stated age, is well developed,  has good posture, is well dressed, well groomed, has good hygiene.

Vital Signs:          

                            BP: 132/83

R: 18 breaths/min unlabored     

P: 100 beats/min, regular

T:98 degrees F (temporal)                 

O2 Sat: 98% on Room air

Height: 5’1”               Weight: 197 pounds        BMI: 36.79 kg/m2

Skin:

Skin around the left eye is crusting and erythematic (erythematous). This painful skin rash extends to halfway of her nose and upwards into her scalp Would like a little more precise description – it’s OK to say that it’s in the distribution of ____ nerve. There are multiple scabs over the left temporal region. The rest of the skin was warm, smooth, mild turgor, nonicteric. There were no lesions, masses, scars, tattoos, thicknesses or opacities or rashes present on the rest of the skin.

Nails:

Normal color size and shape of the nails. Cannot properly tell capillary refill due to nail polish. No spooning, clubbing, beau’s lines fissures, paronychia noted.

Head

Atraumatic, normocephalic. No tenderness or pain on the frontal, temporal, occipital, or parietal areas. No deformities or specific faces noted.

Hair

Skin rash extends into the hair. There is noted crusting and scaling from the rash noted on the upper left scalp and right above the left ear. Good quantity evenly dispersed. Very coarse and no lice noted.

Eyes

The left eye is positive for discharge, redness and stickiness. Patient was not able to open the left eye do to extreme pain so was not able to perform any tests. The right pupil was round and reactive to light, conjunctiva and cornea is clear. No redness, discharge or stickiness was noted. Right eye had proper extraocular movements. If she were not going to ophthalmology, it would be important to document visual acuity – even if minimal – and reactivity to light. 

Ears

Auditory acuity is intact to a whispered voice.

Nose

Symmetrical, no masses lesions or deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection or perforation. No foreign bodies. 

Mouth

Moist mucous membranes without erythema or exudate. Patient had all of her teeth.

Neck

Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM; no stridor noted. No palpable adenopathy noted.

Thyroid

Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Thorax & Lungs 

Chest – Symmetrical, no deformities, no evidence of trauma. Respirations are unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. No tenderness to palpation. 

Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus throughout. No adventitious sounds. 

Musculoskeletal

No ecchymosis, edema, erythema, bleeding, discharge or deformities. Non-tender. Full ROM with discomfort.

Full ROM all other extremities. Strength – 5/5 both upper and lower extremities.  Pt with unsteady gait is unlikely to have perfectly normal LE exam.  Beware if not fully explored, not to document it as normal.

Meningeal signs negative. No nuchal rigidity noted. Brudzinski and Kerning’s signs are negative.

Abdomen

Abdomen flat and symmetric. No striae or pulsations noted. Bowel sounds present in all four quadrants with no aortic/renal/iliac or femoral bruits. Nontender. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Heart

Normal rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Peripheral Vascular Exam

The extremities are normal in color, size and temperature. Peripheral pulses are 2+ bilaterally.

No calf tenderness bilaterally, equal in circumference.  Homan’s sign not present bilaterally. Varicose veins are present bilaterally lower legs. No palpable inguinal or epitrochlear adenopathy. No cyanosis, clubbing / edema noted bilaterally.

Neurological

Mental Status = A/O to person place and time. Memory and attention intact. Receptive and expressive abilities intact; thought coherent. No dysarthria, dysphonia or aphasia noted. Mini-Cog was not performed formally due to the acute illness.

Musculoskeletal: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout.

Differential Diagnoses:

1. Herpes Zoster Ophthalmic
   1. Female that presented with eye pain two weeks ago and then developed a painful rash that does not extend over the halfway point  (“midlne” is more precise since it tells us direction as well) of her nose and only effects the upper left side of the face. The eye has become red, tears constantly, and patient is unable to open the eye. The scabs on the face are also significant for blisters that have crusted over that is consistent with a herpes zoster rash.  Also the development of the symptoms follows the typical pattern for zoster.
2. Viral conjunctivitis
   1. Patient is experiencing irritation, photophobia and watery discharge out of her left eye. Most likely not due to the addition of the rash.
3. Infectious keratitis
   1. Patient is experiencing left eye pain, left eye redness, photophobia of the left eye, left eye excessive tearing and left eye discharge. Is not consistent with the addition and presentation of the rash.
4. Contact dermatitis superimposed on a viral conjunctivitis
   1. Patient is experiencing the left eye irritation, photophobia, and watery discharge. The rash on the left side of the face is consistent with a contact dermatitis. Itchy, painful and a burning sensation. Is not consistent with the addition and presentation of the rash.

Assessment

IM is a reliable 72 year old female with a past medical history of HTN, HLD, and vitamin D deficiency who presents to the geriatric clinic for follow-up after a visit to the ER, due to left eye pain and itchiness, which resulted in a diagnosis of viral conjunctivitis. Her symptoms have persisted and intensified and most likely support a diagnosis of herpes zoster ophthalmic.

Plan:

1. Anxiety
   1. No acute exacerbation. Patient is very uncomfortable due to the left herpes zoster opthalmicus   
   1. Provide patient with proper education of the disease and treatment to try to lessen her anxiety.
2. Herpes Zoster Opthalmicus
   1. Refer for urgent ophthalmology appointment
   1. Prescribe gabapentin 300 mg TID for pain management – to decrease in one week at the next visit
   1. Prescribed acyclovir eye drops Would want to make sure she can administer them – without being able to see with left eye, it will be harder.
3. Obesity
   1. Proper diet was advised
4. Hypertension
   1. BP was acceptable on this visit
   1. Repeat BP on next visit
   1. Continue lisinopril-hydrochlorothiazide treatment 20-25 mg PO daily.
5. Hyperlipidemia
   1. Continue ezetimibe 10 mg PO once daily
6. Vitamin D deficiency
   1. Continue Cholecalciferol 1000 units PO once daily
7. Pre-diabetic There’s nothing here to support this – need at least labs or a notation in the PMH that this has been diagnosed earlier
   1. Diet was discussed with patient
   1. Repeat labs next visit (this visit was to monitor the acute illness)
8. Impaired fasting glucose Same as previous – would actually combine 7 and 8
   1. Diet discussed with patient in detail  
9. COVID
   1. Educated on the importance of vaccination
   1. Will not vaccinate due to acute illness
   1. Plan for vaccination upon resolution of the symptoms
10. PPSV23
    1. Educated on the importance of vaccination
    1. Will not vaccinate due to acute illness
    1. Plan for vaccination upon resolution of the symptoms
11. Shingles Second Vaccine Overdue
    1. Educated on the importance of vaccination
    1. Will not vaccinate due to acute illness
    1. Plan for vaccination upon resolution of the symptoms

1. Quetiapine
   1. Drug Class – Antipsychotic  
   1. Mode of Action – exact mechanism unknown; antagonizes dopamine D2 receptors, serotonin 5-HT2 receptors 
   1. Indications – schizophrenia, bipolar 1 disorder, GAD 
   1. Contraindications – hypersensitivity to drug/class/component, hypokalemia, hypomagnesemia, electrolyte abnormalities, bradycardia, QT prolongation
   1. Side Effects – suicidality, depression exacerbation, tardive dyskinesia, dystonia, TIA, stroke  
   1. Monitoring – lipid panel at baseline, fasting glucose, BP, CBC, weight, suicidality  
   1. Dosage – 50 – 150 mg PO qd  (start 25 mg PO qd then increase by 25-50 mg/day. Max: 300 mg/day). 

• Gabapentin
  • Drug Class – Anticonvulsant  
  • Mode of Action – exact mechanism unknown ; blocks voltage dependent calcium channels.  
  • Indications – partial seizures, post herpetic neuralgia, neuropathic pain, fibromyalgia, alcohol dependence.  
  • Contraindications – hypersensitivity to drug/class/component, CrCl <30
  • Side Effects – depression, suicidality, dizziness, somnolence  
  • Monitoring – Cr at baselines/sx of depression, behavior changes  
  • Dosage – 300-1200 mg PO tid  

• Metoprolol
  • Drug Class – Beta blocker  
  • Mode of Action – selectively antagonizes beta-1 adrenergic receptors  
  • Indications – HTN, angina, Heart failure
  • Contraindications – hypersensitivity to drug/class/component , sinus bradycardia, AV block, heart failure (uncompensated), cardiogenic shock.
  • Side Effects – CHF, bradycardia, heart block, cardiogenic shock, gangrene.  
  • Monitoring – BP, HR 
  • Dosage – 25-100 mg PO qd, may increase dose qwk.

• Levemir – insulin detemir
  • Drug Class – Insulin  
  • Mode of Action – stimulates peripheral glucose uptake, inhibits hepatic glucose production, inhibits lipolysis and proteolysis, regulating glucose metabolism.
  • Indications – diabetes mellitus type 1 and type 2 
  • Contraindications – hypersensitivity to drug/class/component, I’m or IV administration, hypoglycemia
  • Side Effects – hypoglycemia, hypokalemia, hypersensitivity rxn, anaphylaxis  
  • Monitoring – Cr at baseline, K if hypokalemia risk  
  • Dosage – 100 units per mL INJ 
• Famotidine
  • Drug Class – Antacid 
  • Mode of Action – Histamine-2 blockers 
  • Indications – duodenal ulcer, gastric ulcer, GERD 
  • Contraindications – hypersensitivity to drug/class/component 
  • Side Effects – anaphylaxis, angioedema, TEN, SJS 
  • Monitoring – Cr at baseline, then in elderly pts consider periodically 
  • Dosage – 40 mg PO qhs x 4-8 wk