SUBJECTIVE:
Chief Compliant: Rash on face x 4 days
44 y.o female, presents to the ED with red painful rash on right side of face. States it started “Monday”,
so about 4 days ago. Started as a headache with sharp shooting pain, and slowly progressed to a blistery
type rash on the temple and around left forehead and eye, which she points out during our exam. She
states rash has been spreading, but only localized to right side of face, with no left side involvement.
Rash is painful- describes it as “pin-pricks” and “warm”. She says the pain/symptoms do radiate to both
her right eye and left ear as well. Nothing seems to make it better or worse. She has tried nothing for
the rash. Has not had any similar sx before.
She denies any fever, chills, visual changes, blurred vision, no cp, sob/dib, n/v/d.
Pmhx: None- Admits to having Chicken Pox as a child
Surgical h/o: none
Immunizations: Fully immunized
Social H/o: Tobacco/chew: denies, ETOH: denies, Recreational drug use: Denies She is single, lives in an
apartment downriver, and has a cat. Works on the line at GM.
Family h.o: Adopted –no known h/o
OBJECTIVE:
Vital signs: reviewed
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Temperature: 98.0
Heart Rate: 76
Respiratory Rate: 16
Pulse Oximetry: 98
Blood Pressure: 135/90
Home medications: None
Assessment and Plan:
1. Vesicular rash on left side of face, secondary to herpes zoster , with possible involvement of
right eye.
a. Ophthalmology consult for eye exam to r/o intraocular involvement , and negative for
any inner eye/intraocular involvement
b. Acyclovir 1gm po 3x a day for 10d
c. Prednisone 40mg po daily x 5 days
d. Follow-up in 3 days in clinic
2. Left eye, conjunctival irritation, pain, and discharge, secondary to bacterial conjunctivitis
a. Erythromycin Ointment 1 bad bid x 5 days in effected eye
b. Warm compress TID for 5 to 7
c. If worsening sx, change in vision go to ED for re-check
OR
Assessment
1. Vesicular rash on left side of face, secondary to herpes zoster , with possible involvement of
right eye.
2. Left eye, conjunctival irritation, pain, and discharge, secondary to bacterial conjunctivitis
Plan:
a. Ophthalmology consult for eye exam to r/o intraocular involvement , and negative for
any inner eye/intraocular involvement
b. Acyclovir 1gm po 3x a day for 10d
c. Prednisone 40mg po daily x 5 days
d. Follow-up in 3 days in clinic
d. Erythromycin Ointment 1 bad bid x 5 days in effected eye
e. Warm compress TID for 5 to 7
f. If worsening sx, change in vision go to ED for re-check