DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Herpes zoster.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who felt a pustular rash on her posterior lower back about four to five days ago. She then developed lower abdominal pain, which has persisted for the past couple of days and hence came to the emergency department. She denies any fevers, chills, cough, chest pain or shortness of breath. She does have nausea and started vomiting at the present time. She denies any headaches and denies any dysuria. No diarrhea. She was constipated and hence took magnesium citrate yesterday. She has had loose stools since then.
PAST MEDICAL HISTORY: Unremarkable.
PAST SURGICAL HISTORY: Unremarkable.
MEDICATIONS: The patient is ordered to get Valtrex and Cipro.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient does smoke, but denies alcohol use.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: As per HPI, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.8 degrees, pulse 82, respirations 20, and blood pressure 188/58.
HEENT: Unremarkable.
NECK: No lymphadenopathy.
LUNGS: Clear to auscultation.
HEART: S1 and S2, regular rhythm.
ABDOMEN: Left lower quadrant tenderness. No rebound, guarding or rigidity. Bowel sounds present.
BACK: Left posterior lower flank area with papular rash almost in the dermatomal distribution.
NEUROLOGICAL: No focal neurological deficits.
LABORATORY DATA: White count 5.8, hemoglobin 14.2 and platelets 212. BUN and creatinine 10.2 and 0.8. Urinalysis shows negative leukocyte esterase.
DIAGNOSTIC DATA: Chest x-ray revealed no acute infiltrate. CT of the abdomen and pelvis was unremarkable, except chronic-appearing interstitial infiltrates on the lung bases. No abdominal pathology.
IMPRESSION:
1. The rash appears to be consistent with herpes zoster.
2. Left lower quadrant abdominal pain could be referred pain.
RECOMMENDATION:
1. Since the patient is vomiting, we would switch oral Valtrex to IV acyclovir.
2. We would discontinue Cipro.
3. If it improves in the next 24 hours, could switch to oral Valtrex.
