Chief Complaint: “My back has been itchy for the past three days”

History of Present Illness:

            G.W. is an 81-year-old M resident w/ a PMHx HTH, HLD, BPH, GBS, major depressive disorder, and insomnia admitted to Gouverneur’s skilled nursing facility four years ago. He complains of pruritus along the RT side of his back x3 days. As per patient, the itch is constant and has been worsening since onset. He describes it as a tingly, burning sensation that travels from the RT side of the back of his neck to the midportion of his back. He states that his wife has been applying ammonium lactate to the area, but he does not experience any relief. Collateral was obtained from wife who states that she noticed a rash in the area where he complains of pruritus about 2 days ago. She reports he has a history of fungal infections but that this rash does not look like his typical fungal rash. As per wife, there are small clusters of fluid filled blisters, and multiple areas of erythema distributed along the back and neck. Patient denies fever, chills, fatigue, weakness, chest pain, blurry vision, SOB, palpitations,  nausea, vomiting, diarrhea, constipation, abdominal pain, recent travel, recent sick contacts, gross skin swelling, purulent discharge, sloughing of the skin, or current topical/PO steroid use.

Geriatric Assessment

• ADLs: Dependent in dressing, using the bathroom, and personal hygiene
• IADLs: Dependent in transportation, preparing meals, cleaning, and doing laundry
• Home Health Aide: N/A
• Visual impairment: Yes, patient uses shades; eyes are sensitive to light
• Hearing impairment: None  
• Falls in the past year: Three
• Assistive devices used: wheelchair
• Gait impairment: Patient requires wheelchair for ambulation
• Urinary incontinence: None
• Fecal incontinence: None
• Cognitive Impairment: None
• Depression: Hx Major Depressive Disorder  
• Home safety issues: patient resides at SNF  
• Health Care Proxy: Wife, M.W.
• Advance Directives: Full code  

Past Medical History:

• Hypertension
• Hyperlipidemia
• Benign prostatic hyperplasia
• Hx Prostate Cancer
• Guillan Barre Syndrome
• TBI 2/2 MVA
• Major depressive disorder
• Generalized anxiety disorder
• Chronic constipation
• Insomnia
• Hx pulmonary embolism

Immunization History:  

• Vaccinations up to date except for influenza and RSV; both are contraindicated due to GBS

Preventative Medicine Screening:

Colonoscopy – patient does not recall, wife does not recall

Dental – 09/11/2024: patient requires “crown and core buildup”; partial dentures well-fitting

Ophthalmologic – appointment for mid-October, patient has developed sensitivity to light

Past Surgical History:

Bilateral hip replacement

Herniated disc L1-L2 laminectomy

Medications:

• Lisinopril 2.5 mg PO daily for HTN
• Atorvastatin 40 mg PO at bedtime for Hyperlipidemia
• Sertraline HCl 25 mg PO daily for major depressive disorder
• Tamsulosin HCl 0.4 mg PO daily for BPH
• Polyethylene Glycol 3350 1 scoop PO daily for chronic constipation
• Melatonin 3 mg PO at bedtime for insomnia
• Eliquis 5 mg PO BID for “other pulmonary embolism”
• Acetaminophen 2 tablets PO

Allergies:

Allergies to iodine and calcium channel blockers, reaction unknown

Denies environmental or food allergies

Family History:

• Mother, deceased; died secondary to breast cancer at unknown age
• Father, deceased; died secondary to myocardial infarction at unknown age
• Brother, deceased; died secondary to prostate cancer at age 72

Social History:

G.W. is an 81-year-old M domiciled at Gotham Health Gouverneur’s SNF. He is visited daily by his wife. His children visit on the weekends.

Habits – No current tobacco, alcohol, or drug use. Patient states he drank excessively for 30 years but stopped after his TBI.

Travel – No recent travel

Diet – heart healthy diet, regular texture, thin consistency

Sleep – patient sleeps majority of the night, takes 1-2 naps a day

Safety measures – patient is a fall risk, must use call bell for wheelchair transfer

Occupation – retired, used to work in accounting

PCP – Dr. Gilchyonok

Proxy – Wife, M.W

Review of Systems:

General: Denies fever, chills, night sweats, fatigue, weakness, loss of appetite, recent weight gain or loss

Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution

HEENT: Admits to use of partial dentures. Denies headache, vertigo, head trauma, unconsciousness, coma, use of contacts, glasses, visual disturbances, fatigue, lacrimation, photophobia, deafness, pain, discharge, tinnitus, use of hearing aids, nasal discharge, epistaxis, bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes

Neck: Admits pruritus on RT neck radiating to midback. Denies localized swelling/lumps, stiffness/decreased range of motion

Pulmonary system: Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND

Cardiovascular system: Denies chest pain, HTN, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur

Genitourinary: Reports occasional frequency, urgency. Denies nocturia, incontinence, dysuria, oliguria, or pyuria  

Males: Last PSA: 09/10/2024. Reports occasional hesitancy, dribbling

Sexual history: Sexually active? No

Musculoskeletal System: Denies muscle/joint pain, deformity or swelling, redness, arthritis

Peripheral Vascular System: Admits brawny colored bilateral LE (chronic). Denies varicose veins, or peripheral edema, color change

Hematologic System: Denies easy bruising or bleeding, lymph node enlargement, hx of clot

Endocrine System: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Nervous System: Denies seizures, loss of consciousness, loss of strength, change in cognition/mental status/memory, weakness

Psychiatric: Reports history of major depression and generalized anxiety disorder

Vital Signs:       

Temperature: 98.0 degrees Fahrenheit

O2 Sat: 95% on room air

Height: 71 inches

Weight: 200.6

BMI:  28 kg/m2

Respiratory Rate: 18 breaths per minute

Heart Rate: 68 beats per minute

Blood Pressure: 138/68, RT arm lying down

Physical:

General: Patient appears clean & well groomed, alert & oriented to time, place, and person. He is lying comfortably in bed, appears stated age, and is not in acute distress.

HEENT: Hair is white in color with silky texture and no sign of lice or nits. Head is normocephalic and atraumatic. Face is symmetrical with no signs of drooping, swelling, or trauma. Eyes are symmetrical OU, conjunctiva is white. Bilateral ears are symmetrical and appropriate in size without lesions, masses, or trauma on external ears. The nose symmetrical without masses, deformities, trauma, or discharge. Well-fitting dentures noted. No gingival hyperplasia or erythema. Pharynx is non-erythematous, uvula is midline.

Skin and Nails: Grouped vesicular lesions with erythematous base on the RT-most part of back and neck. Scaly, circular lesions with central clearing of various sizes noticed on the LT mid-back. The skin is warm and moist with good texture and turgor. Non-icteric with no swelling or signs of ecchymosis.

Nails do not exhibit digital clubbing, capillary refill less than 2 seconds in upper extremities.

Neck, Thyroid, and Lymph Nodes: The trachea is midline without masses or scars. The lymph nodes are freely mobile and non-tender.

Cardiac: No carotid bruits on auscultation. S1 and S2 are normal. No murmurs, S3, or S4 sounds on auscultation. No friction rubs or gallops noted.

Thorax and Lung:  Chest is symmetrical with no signs of deformity, or trauma. There are no scars or rashes. Respirations are unlabored without use of any accessory muscles. Patient has good airflow. No wheezing, rhonchi, or rales noted.

Abdomen: Abdomen is round and without rashes, bruising, or masses. Bowel sounds normoactive in all four quadrants. Non-tender to palpation, no guarding or rebounding noted.

Mental Status Exam: Patient is alert and oriented to name, date, time, and location. Speech and language ability intact, with normal quantity, fluency, and articulation. Conversation progresses logically. Insight, judgement, cognition, memory, and attention intact.

Peripheral Vascular Exam: The extremities are brawny in color. There is atrophy of bilateral lower extremities, +1 edema bilaterally, darkish discoloration of b/l lower extremities, elongated toenails. No calf tenderness bilaterally.  Homan’s sign not present bilaterally. Skin normal in color and warm to touch upper extremities bilaterally. No ulcerations noted

MSK Upper Extremity:  No soft tissue swelling, erythema, ecchymosis, atrophy, or deformities in bilateral upper extremities.

DDx:

1. Herpes zoster
2. Tinea corporis
3. Contact dermatitis: allergic vs irritant
4. Impetigo

Laboratory Findings

CMP w/ Magnesium & Phosphate                                   CBC w/ Differential

Anion Gap	11		WBC	3.92		Basophil %	0.3
Sodium	141		RBC	4.66		Basophil Abs	0.01
Potassium	4.0		HGB	14.3		Imm Gran %	1.3
Chloride	105		HCT	45.8		LDH	188
Co2	24		MCV	98.3		PSA	4.83
BUN	9		MCH	30.7
Creatinine	0.45		MCHC	31.2
Glucose	98		RDW	13.7
ALT (SGPT)	20		PLT	106
AST (SGOT)	12		MPV	N/A
Alkaline Phosphate	87		Monocyte %	7.9
Total Bilirubin	0.4		Monocyte Abs	0.31
Calcium	8.9		Neutrophils Abs	1.66
Total Protein	6.0		Neutrophil %	42.2
Albumin	3.8		Lymphocyte Abs	1.88
Magnesium	N/A		Lymphocyte %	48.0
Phosphorus	N/A		Eosinophil %	0.3
eGFR	106		Eosinophil Abs	0.01

Assessment:

G.W. is an 81-year-old M resident w/ a PMHx HTH, HLD, BPH, GBS, major depressive disorder, and insomnia complaining of pruritus along the RT side of his back x3 days. Patient has a history of fungal skin infection as per collateral from wife. Two distinct rashes were visualized on physical exam: grouped vesicular lesions in two adjacent dermatomes, and scaly circular lesions with a central clearing.

Plan:

#herpes zoster

• Initiate Valacyclovir 1 gm TID x14 days
• If no improvement noted, consider dermatology consult
• Monitor LFTs
• Monitor for worsening erythema, warmth, discharge
• Hold topical fungal cream

#pressure ulcer ppx

• Turn patients every 1-2 hours