Age: 68.0
Sex: M
Vaccine: VARZOS
Symptoms: Pain in extremity, Paraesthesia, Rash vesicular, Skin lesion, Skin warm
Clinical narrative: Patient's wife, was diagnosed with shingles and treated accordingly by Dr. As family physician, Dr. immediately sent patient to be vaccinated. On 8/6/09 patient purchased Merck shingle's vaccine at pharmacy. He drove across the street to Dr.'s office. Where the vaccine was administered within the recommended timeframe. Refer to medical records Dr.'s Medical Office. On April 1, 2010, patient started having pain on the left side of his face, back and shoulder. He awakened wife at 3 am with sharp pains, strong tingling and warmness. On Saturday and Sunday there was no relief. He then complained with severe head pain radiating from the left side of his head and back to the left eyeball. This is very unusual for him as he rarely complains but continued to suffer from stinging, burning terrible pain. He reported to Dr.'s office Monday AM where he was seen by the Physician's Assistant. She diagnosed shingles, even though he had received the vaccination on 8/8/2009 which would have about 8 months before said outbreak. Dr.'s office immediately referred him to Dr., Ophthalmologist. He has been in his care since then with problems in both eyes. Dr. referred him to a retina specialist. He has dealt with the pain and progressively worsening eyesight. Our concern is that he may lost sight all together. 4-6-10 69 y.o. HA over the last 5 days and also lump on his neck on left side. Reporting 3-4 wks has sharp pain into left arm and sore muscles over his left shoulder when he stretches. Is waking up about 3am with this sharp pain but then tingles and goes away. Denies CP/SOB. No impending doom, no diaphoresis, N/V. He states then on Sunday this past wk, it started with a HA on left side of his head and back into his eyeball. He said it was a stinging, burning pain and comes around the side of his head towards his eye. No recent contact known. Slightly TTP at left occipital area, left side. Skin non tender though small 2mm area that appears reddened, spot. Some appear to forming vesicles. Going from suboccipital over to the occipital lobe behind the left ear across the cheek onto the nose on the left side. Left conjunctiva erythemic with some injection. Left outside bottom edge with lesion noted. Sclera erythemic, no lesions noted on cornea. Snellen chart shows 20/20 left. Comparing sides no lesion. No TTP, eye remains clear, sclera and conjunctiva. No lesions noted on LUE. Shingles vax 8-06-09. Probable Herpes Zoster. Acyclovir 200 mg q x 10days number 60 NRF. Prednisone 30mg tapering dose over 3 wks. PERCOCET 5/500 number 60 NRF. Amitriptyline 25mg number 30 NRF. FU with Dr. Ophthalmologist Wed or Thurs. 4-13-10 69 yo FU from shingles. Has seen Dr. who has confirmed dx of herpes zoster. Currently pt informs that the retina has lesions, though there are no ulcerations. The cornea has lesion but no ulcerations. Currently on Prednisone eye drop, oral steroids. Continues with Acyclovir and Amitriptyline. Denies having neuralgia, only periodic sensations. L temporal dried vesicular lesions high up on scalp. Erythemic lesions across L cheekbone and onto the bridge of the nose. Nonvesicular. Sclera of the L eye severely erythemic. Conjunctiva injected with lesion noted L lower lid, outer. Lymphadenopathy posterior, cervical resolved. Lymphadenopathy resolved, herpes zoster, impaired vision, HTN elevated (on oral steroids). FU Dr. COC all meds as Dr. will complete treatment regime. COC after treatment completed for BP monitoring and treatment.