MDM - Shingles

[##]-year-old [male/female] with [rash/burning pain to the location] with history and exam consistent with likely herpes zoster (shingles).

Initial considerations in this patient included varicella zoster virus reactivation (shingles), bullous pemphigoid, primary varicella, contact dermatitis, disseminated gonoccal disease, and other infectious and non-infectious etiologies of rash amongst others.

Patient presents with [maculopapular/vesicular] rash to the [location] in a dermatomal distribution that does not cross the midline suggestive of shingles.  Patient describes [current/antecedent] pruritus, paresthesia, and pain consistent with shingles.  Patient [reports/denies] history of prodromal symptoms [describe headache, malaise/etc.].  [Patient noted to have rash to the face without evidence of eye pain or redness, involvement of the tip of the nose (Hutchinson’s sign), or other findings suggestive of ophthalmic involvement (herpes ophthalmicus).]  [Patient noted to have no evidence of vesicular lesions to the tympanic membrane to suggest otic involvement (Ramsey-Hunt syndrome).]  Patient [noted to be/reports being] up to date on vaccinations including for varicella.  No evidence of disseminated rash, severe disease, or systemic symptoms to suggest immunocompromise in this patient.

Prior to discharge, we discussed analgesia with [NSAIDs/opiodis/Gabapentin] and Diphenhydramine for pruritis.  We discussed starting [Acyclovir/Valacyclovir] antiviral treatment [given presentation les than 72 hours from onset of rash and likely benefit/despite lower likelihood of benefit given presentation over 72 hours from the onset of rash given low risk of harm from this treatment].  Glucocorticoids [were/were not] given at this time after consideration and discussion with the patient of limited evidence of benefit and potential harms of this treatment (such as hyperglycemia and transient immunocompromise). 

We discussed return precautions and recommended follow up with primary care provider within one week, and the patient demonstrated understanding and agreement with this plan.