Can you write a detailed SOAP note for an 84-year-old woman with herpes zoster involving the right scalp, right V1/V2 facial distribution down to the cheek, with no optic nerve involvement?

SOAP Note: 84-Year-Old Female with Herpes Zoster (Shingles)

Subjective

Chief Complaint:

• Painful vesicular rash on right scalp and right side of face extending to cheek 1

History of Present Illness:

• Patient reports prodromal pain that likely preceded the rash by 24-72 hours, characterized by burning, tingling, or paresthesia in the affected dermatome 2
• Vesicular eruption developed in a unilateral dermatomal distribution involving the right V1/V2 trigeminal distribution 1, 2
• Lesions progressed from erythematous macules to papules and then to vesicles, with possible coalescence 3
• Duration of symptoms should be documented to determine if within the 72-hour window for optimal antiviral efficacy 1
• Severity of acute pain should be quantified using a pain scale 4

Past Medical History:

• Document any immunocompromising conditions including diabetes mellitus, malignancy, HIV/AIDS, rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease, or cardiovascular disease 5
• Current medications, particularly immunosuppressive agents (corticosteroids >40mg daily, biologics, JAK inhibitors, chemotherapy) 1
• History of varicella (chickenpox) infection or varicella vaccination 5
• Prior herpes zoster episodes 5
• Vaccination history, specifically recombinant zoster vaccine (Shingrix) status 1

Review of Systems:

• Ophthalmic: No eye pain, vision changes, or photophobia (optic nerve unaffected per presentation) 6
• Constitutional: Fever, malaise, or weight loss suggesting disseminated disease 1
• Neurologic: Headache, confusion, or focal neurologic deficits suggesting CNS involvement 1
• Respiratory: Cough or dyspnea suggesting pulmonary involvement 1
• Gastrointestinal: Abdominal pain or elevated liver enzymes suggesting hepatic involvement 1

Objective

Vital Signs:

• Temperature, blood pressure, heart rate, respiratory rate, oxygen saturation 1

Physical Examination:

Dermatologic:

• Distribution: Unilateral vesicular eruption in right V1/V2 dermatomal distribution involving right scalp and right side of face extending to cheek 1, 2
• Lesion characteristics: Thin-walled vesicles on erythematous base, possible pustules or early ulceration, assess for coalescence 3, 2
• Stage of lesions: Document if lesions are still erupting (typically 4-6 days in immunocompetent hosts) or if any have begun to crust 3, 2
• Assess for dissemination: Examine for lesions in >3 dermatomes, which would indicate disseminated disease requiring IV therapy 1
• Hutchinson sign: Examine nasal tip for vesicles, which indicates nasociliary nerve involvement and higher risk of ocular complications 6

Ophthalmologic:

• Visual acuity: Document baseline vision in both eyes 6
• External examination: Eyelid edema, vesicles on eyelid margins, conjunctival injection 5, 6
• Corneal examination: Punctate keratitis, pseudodendritic lesions (requires slit lamp by ophthalmology) 5
• Pupillary response: Assess for afferent pupillary defect 6
• Intraocular pressure: Elevated IOP suggests uveitis or trabeculitis 5
• Given facial/V1 involvement, urgent ophthalmology consultation is mandatory even without current symptoms 1, 6

Lymphatic:

• Palpable preauricular or cervical lymphadenopathy 5

Neurologic:

• Cranial nerve examination, particularly CN V sensory function 6
• Mental status if concern for encephalitis 1

General:

• Assess for signs of immunocompromise or systemic illness 1

Assessment

Primary Diagnosis:

• Herpes zoster (shingles) involving right V1/V2 trigeminal distribution 1, 2, 4

Risk Stratification:

• Age 84 years: High risk for postherpetic neuralgia (PHN) and complications 5, 7
• Facial involvement: Requires heightened vigilance for ophthalmic complications despite current lack of optic nerve involvement 1, 6
• Immunocompetent vs. immunocompromised: Determine based on history and examination to guide therapy intensity 1, 3

Complications to Monitor:

• Herpes zoster ophthalmicus with potential for keratitis, uveitis, retinitis, vision loss 5, 6
• Postherpetic neuralgia (most common complication, risk increases with age) 5, 4, 7
• Cranial nerve palsies 5
• Secondary bacterial superinfection 5, 3
• Disseminated disease (if immunocompromised) 1, 3

Plan

Immediate Management

1. Urgent Ophthalmology Referral:

• Mandatory ophthalmology consultation within 24 hours due to V1 distribution involvement, regardless of current symptoms 1, 6
• Risk of vision-threatening complications including keratitis, uveitis, and retinitis requires specialist evaluation 5, 6

2. Antiviral Therapy (Initiate Immediately):

For immunocompetent patient:

• Valacyclovir 1000 mg orally three times daily for 7-10 days 1, 4
• Alternative: Famciclovir 500 mg orally three times daily for 7-10 days 1, 4
• Alternative: Acyclovir 800 mg orally five times daily for 7-10 days (requires more frequent dosing, less preferred) 1, 4
• Treatment must be initiated within 72 hours of rash onset for optimal efficacy in reducing acute pain, accelerating lesion healing, and preventing PHN 1, 4
• Continue treatment until ALL lesions have completely scabbed, not just for an arbitrary 7-day period 1

For immunocompromised patient or complicated disease:

• Intravenous acyclovir 10 mg/kg every 8 hours 1, 3
• Indications for IV therapy: disseminated disease (>3 dermatomes), severe immunosuppression, CNS complications, complicated ocular disease, or failure to respond to oral therapy within 7-10 days 1
• Continue IV therapy for minimum 7-10 days and until clinical resolution (all lesions scabbed) 1
• If immunocompromised, consider temporary reduction or discontinuation of immunosuppressive medications if clinically feasible 1

Renal dose adjustments:

• Obtain baseline creatinine clearance 1
• Valacyclovir: Adjust dose based on CrCl 1
• Famciclovir: 500 mg q8h for CrCl ≥60; 500 mg q12h for CrCl 40-59; 500 mg q24h for CrCl 20-39; 250 mg q24h for CrCl <20 1
• Monitor renal function weekly during IV acyclovir therapy 1

3. Pain Management:

Acute pain control:

• Acetaminophen 650-1000 mg orally every 6 hours as needed 1
• Ibuprofen 400-600 mg orally every 6-8 hours as needed (if no contraindications) 1
• Topical ice or cold packs to affected area 1
• For severe pain: Consider short-acting opioids (e.g., oxycodone 5-10 mg every 4-6 hours) 4
• Avoid topical anesthetics as primary therapy (minimal benefit) 1

Adjunctive therapy for severe acute pain:

• Consider gabapentin 300 mg orally three times daily, titrate as needed 4, 8
• Consider pregabalin 75 mg orally twice daily, titrate as needed 4, 8
• Corticosteroids (prednisone) may be considered as adjunctive therapy in select cases of severe, widespread disease, but carry significant risks in elderly patients 1
• Avoid corticosteroids if immunocompromised due to risk of disseminated infection 1

4. Skin Care:

• Keep lesions clean and dry 5
• Avoid applying topical products to active vesicular lesions 1
• Emollients may be used after lesions have crusted to prevent excessive dryness 1
• Monitor for secondary bacterial infection (increased erythema, purulent drainage, warmth) 5, 3

5. Infection Control:

• Patient must avoid contact with susceptible individuals (pregnant women, immunocompromised, unvaccinated individuals, neonates) until ALL lesions have crusted 1
• Cover lesions with clothing or dressings to minimize transmission risk 1
• Lesions are contagious to individuals who have not had chickenpox or vaccination 1

Laboratory Testing

Baseline studies:

• Serum creatinine and calculated CrCl (for antiviral dosing) 1
• Complete blood count (if concern for immunosuppression) 1
• Glucose or HbA1c (diabetes screening, as HZ may unmask metabolic disease) 2

Confirmatory testing (if indicated):

• PCR of vesicle fluid (most sensitive/specific, approaching 100%) - indicated if immunocompromised, atypical presentation, or diagnostic uncertainty 2, 4, 8
• Direct immunofluorescence (DFA) antigen testing of vesicle fluid (rapid alternative to PCR) 2
• Tzanck smear (bedside adjunct showing multinucleated giant cells, cannot differentiate VZV from HSV) 2, 4
• Viral culture (less practical, longer turnaround) 2
• Do NOT order VZV IgG/IgM serology (does not aid in acute diagnosis) 2

Additional screening:

• Consider HIV testing if risk factors present or recurrent HZ 5, 2
• Consider evaluation for occult malignancy if clinically indicated 5, 2

Monitoring and Follow-Up

Short-term monitoring:

• Daily ophthalmology follow-up if any ocular symptoms develop (eye pain, vision changes, photophobia) 6
• Reassess in 3-5 days to ensure lesions are responding to therapy 1
• If lesions fail to begin resolving within 7-10 days, suspect acyclovir resistance and obtain viral culture with susceptibility testing 1
• Monitor for signs of dissemination: new lesions in distant dermatomes, fever, respiratory symptoms, neurologic changes 1
• Continue antiviral therapy until ALL lesions have completely scabbed 1

Treatment failure or resistance:

• For confirmed acyclovir-resistant VZV: Foscarnet 40 mg/kg IV every 8 hours until clinical resolution 1
• Acyclovir resistance is rare in immunocompetent patients but occurs in up to 7% of immunocompromised patients 1

Long-term monitoring:

• Assess for development of postherpetic neuralgia (pain persisting >30 days after lesion healing) 4, 7
• If PHN develops: Gabapentin, pregabalin, tricyclic antidepressants (amitriptyline, nortriptyline), or long-acting opioids are first-line treatments 4, 8
• Topical lidocaine 5% patch or capsaicin cream as second-line agents for PHN 4, 8

Prevention of Future Episodes

Vaccination:

• Strongly recommend recombinant zoster vaccine (Shingrix) after recovery from current episode 5, 1
• Shingrix provides >90% efficacy in preventing future HZ episodes and is recommended for ALL adults ≥50 years regardless of prior HZ episodes 5, 1
• Two-dose series: Second dose 2-6 months after first dose 5
• Can be administered after recovery from acute HZ episode 5, 1

Patient Education

Disease course:

• Explain that lesions typically continue to erupt for 4-6 days with total disease duration of approximately 2 weeks in immunocompetent hosts 3, 2
• Emphasize importance of completing full antiviral course until all lesions scab 1
• Discuss risk of postherpetic neuralgia, which increases with age (up to 50% in those >80 years) 5, 7

Warning signs requiring immediate return:

• Eye pain, vision changes, or photophobia 6
• New lesions in distant body areas (suggesting dissemination) 1
• Fever, severe headache, confusion (suggesting CNS involvement) 1
• Respiratory symptoms (suggesting pulmonary involvement) 1
• Signs of secondary bacterial infection (increased redness, pus, warmth) 5, 3

Transmission precautions:

• Avoid contact with pregnant women, immunocompromised individuals, unvaccinated persons, and neonates until all lesions crust 1
• Cover lesions with clothing or dressings 1
• Practice good hand hygiene 8