DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
PRINCIPAL DIAGNOSES:
1. Disseminated herpes zoster.
2. Total body surface area greater than 5% open and ulcerated skin secondary to herpes zoster rash.
3. Postherpetic neuralgia.
4. Acquired immunodeficiency syndrome.
5. Candida esophagitis and gastritis.
6. Depression.
PROCEDURES PERFORMED: Endoscopy.
FINDINGS: Enterogastritis, reflux esophagitis and esophageal candidiasis.
CONSULTATIONS:
1. Psychiatry. The patient was found to have nonsuicidal depression.
2. Gastroenterology.
3. Pain management.
4. Infectious disease.
HISTORY OF PRESENT ILLNESS: The patient presented with disseminated zoster to the emergency department after a one-week course, not improving, after treatment for musculoskeletal shoulder pain by an outside physician. It is clear that the patient had disseminated zoster with multi dermatomal distribution at the time of presentation. His most involved dermatomes were the C6-C7 dermatome and T11 dermatome. His prior history included the fact that he had been treated previously by a local infectious disease physician and has not had any therapy for at least the past two years. He has longstanding history of depression for which he has been treated with Zyprexa and Effexor in the past and states this has not been really helpful. He was hospitalized for depression but presented at admission with zoster.
PAST MEDICAL HISTORY: Significant for asthma, AIDS and the recurring zoster that is recurring for the fourth time on admission.
PAST SURGICAL HISTORY: None.
MEDICATIONS AT ADMISSION: None.
HOSPITAL COURSE: Disseminated zoster: The patient had diffuse and wide open lesions consistent with disseminated zoster that were painful over his C6, right arm, as well as his left T11 area. He was initially started on 5 mg/kg of acyclovir and actually continued to have new lesions noted and scattered over the thorax, at which point his acyclovir was continued for seven days at 10 mg/kg q. 8 hours. The patient tolerated this dose well, and he has had good resolution of his active zoster lesions with no new lesions for the past six days prior to the time of discharge. He will be continued on seven days of Valtrex 1000 mg p.o. t.i.d. as an outpatient.
ASSESSMENT AND PLAN:
1. To follow up with Dr. John Doe or the infectious disease doctor.
2. Open zoster rash. Local wound care was initiated. Ancef was given for five days. He had no secondary cellulitis. At discharge, he is on Xeroform gauze every three days covered with regular plane gauze wrap for protection of the skin. At this point, he has no evidence of any skin breakdown, but there is some concern for ongoing scar, and he will require ongoing wound care for his disseminated zoster as noted over the left T11 and right C6 areas.
3. Postherpetic neuralgia. The patient had remarkable pain and required significant amounts of pain medications during this hospitalization. He was titrated up in terms of his gabapentin. He is discharged on 600 mg p.o. t.i.d. He is also on p.r.n. Dilaudid. He also has pain over his right anterior shoulder that is responding well to Lidoderm, as this is an intact area above the area of zoster rash below his shoulder. He states that he is able to control, and he gives a pain score of 2 to 3 when he is in low pain and 7 to 8 when his pain is worsened.
4. Acquired immunodeficiency syndrome. The patient has been placed on Viread as well as Combivir. He will be discharged to home on these and will follow up Dr. Jane Doe. In addition, he has been started on prophylaxis, as the CD4 count is 9. Started on Bactrim DS one p.o. daily. Started on azithromycin 200 mg p.o. weekly. Follow up with ID regarding his ongoing HIV care. Labs are pending at the time of discharge.
5. HIV-1 genotype drawn. HIV viral load is 22,490. CD4 count is 9. RPR nonreactive. Hepatitis panel nonreactive, hepatitis A IgM nonreactive, hepatitis B Core IgM nonreactive, hepatitis B surface antigen nonreactive, and hepatitis C IgG.
6. Candida esophagitis. Endoscopy showed Candida esophagitis. We are going to stop his Protonix and start him on Diflucan. He received a 200 mg IV dose loading and is currently on 100 mg p.o. daily and will continue this as an outpatient to complete course and follow up with his primary care physician.
7. Depression. He has had prior hospitalizations for depression. Most of his problems are related to inability to continue his medications. He now has insurance. He has been started on Zyprexa 10 mg p.o. daily as well as Lexapro 10 mg p.o. daily. Follow up with his PCP and possible psychiatric followup is needed, if he is not responding to these doses of medications.
DISCHARGE MEDICATIONS:
1. Viread 300 mg p.o. daily.
2. Combivir orally b.i.d.
3. Gabapentin 600 mg p.o. t.i.d.
4. Lidoderm patch topically q. 12 hours, then off 12 hours over the right anterior shoulder.
5. Lexapro 10 mg p.o. daily.
6. Zyprexa 10 mg p.o. daily.
7. Phenergan 25 mg p.o. q. 6 hours p.r.n. for nausea.
8. Diflucan 100 mg p.o. daily x10 days.
9. Valtrex 1000 mg p.o. three times daily for seven days.
10. Dilaudid 4 mg p.o. q. 4 hours p.r.n. for pain, quantity 40.
11. Bactrim DS one p.o. every other day.
12. Azithromycin 200 mg orally weekly.
DISCHARGE DIET: Regular diet.
DISCHARGE ACTIVITY: Ad lib.
CONDITION ON DISCHARGE: Stable.
FOLLOWUP VISITS: Outpatient wound care needs to be arranged. The patient is to follow up with Dr. John Doe regarding ongoing AIDS care until he is able to contact special care unit. Follow up with Dr. Jane Doe for new PCP.
