Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint: Briefly describe the patient’s main concern. This might include:
Location and duration of rash
Pain level (sharp, burning, stabbing)
Presence of fever, malaise, or other systemic symptoms
History of Present Illness:
Date of rash onset
Description of rash evolution (progression, blistering)
Any known triggers for zoster (stress, immunosuppression)
Prior history of chickenpox or varicella vaccination
Past Medical History:
Underlying medical conditions (diabetes, HIV/AIDS)
Immunosuppressive medications
Allergies (especially to antiviral medications)
查体 (chá tǐ) Physical Examination:
General appearance (fever, malaise)
Dermatologic exam:
Location and distribution of rash (unilateral, dermatomal pattern)
Presence of vesicles, pustules, or crusted lesions
Assessment of pain (allodynia, hyperalgesia)
Neurologic exam (if facial involvement or suspected complications)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Viral testing for herpes zoster (usually not necessary with classic presentation)
Blood sugar (if diabetes is a concern)
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies: (Rarely needed)
MRI/CT scan (if neurological complications suspected)
诊断 (zhěn duàn) Diagnosis:
Herpes zoster (specify location, e.g., thoracic, ophthalmic)
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Antiviral medications (acyclovir, valacyclovir, famciclovir) – duration based on severity
Pain management (topical anesthetics, gabapentin, pregabalin)
Skin care (wet compresses, drying agents)
Ophthalmic evaluation and treatment (if ophthalmic involvement)
预后 (yù hòu) Prognosis:
Discuss typical course of shingles and potential complications (post-herpetic neuralgia)
Importance of early treatment to reduce risk of complications
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Explain herpes zoster and the cause
Importance of adhering to medication regimen
Pain management techniques
Skin care instructions
Warning signs of complications (worsening pain, vision changes)
Importance of vaccination to prevent shingles (if appropriate)
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment to monitor healing and address any complications