A Blister on the Tip of the Nose: A Focused Skin and Eye Examination Note for Herpes Zoster Ophthalmicus in a 66-Year-Old Woman, and the Sign That Sent Her to Ophthalmology the Same Day
[Student Name]
University of Phoenix
NRP/531: Advanced Health Assessment I
Week 3 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
Subjective
Mrs. B., a 66-year-old retired bank teller, presents with two days of burning pain over the left forehead and scalp, followed yesterday by a rash in the same area. This morning her left eye became red and watery, and light bothers it. She denies vision loss, but reading is uncomfortable. She had chickenpox as a child and has not received a shingles vaccine. Her only chronic condition is type 2 diabetes, for which she takes metformin; she has no immune-suppressing illness and takes no immune-suppressing drugs. No known drug allergies.
Objective
She is afebrile at 37.4 °C, with a blood pressure of 138/82 mm Hg and a pulse of 84.
Skin: grouped vesicles on an erythematous base, some crusting, in a band over the left forehead and upper eyelid extending into the scalp, stopping sharply at the midline. Two vesicles on the left side of the tip of the nose. No lesions on the right side of the face. Left upper eyelid mildly edematous.
Eyes: visual acuity 20/25 right, 20/40 left with glasses. Left conjunctiva injected, more around the limbus; clear watery discharge; photophobia. Pupils equal and reactive, no afferent defect. Fluorescein staining with a cobalt blue light shows a small branching area of uptake on the left cornea. Right eye normal.
Lymph nodes: tender left preauricular node.
Neurological: sensation reduced to light touch in the left forehead; cranial nerves otherwise intact.
Assessment
Herpes zoster ophthalmicus, left, with Hutchinson's sign and probable keratitis.
Plan
Valacyclovir 1 g by mouth three times daily for seven days, started today. Same-day ophthalmology evaluation, arranged by phone. Acetaminophen for pain and cool compresses. Keep lesions covered and avoid contact with pregnant women, infants and immunocompromised people until lesions crust. Recombinant zoster vaccine to be discussed after recovery. Return or call for vision change, severe headache or confusion.
Two vesicles smaller than a pencil eraser turned an uncomfortable rash into an eye emergency.
Why the Distribution Matters
Herpes zoster results from reactivation of varicella-zoster virus that has remained latent in a sensory ganglion since childhood chickenpox. Reactivation produces pain and then a rash in the dermatome supplied by that ganglion, typically on one side and stopping at the midline (Cohen, 2013). Mrs. B.'s rash follows the ophthalmic division of the trigeminal nerve, the first division, which supplies the forehead, upper eyelid and, through the nasociliary branch, the eye and the tip of the nose.
Why Hutchinson's Sign Matters
Because the nasociliary branch supplies both the tip of the nose and the eye, vesicles on the nose signal that the branch serving the eye is involved. In a study of patients with herpes zoster ophthalmicus, Hutchinson's sign was a strong predictor of ocular inflammation, with a relative risk of 3.35, and of corneal denervation, with a relative risk of 4.02 (Zaal et al., 2003). Mrs. B.'s red eye, photophobia and corneal staining confirm what the sign predicted.
Why the Eye Examination Must Be Complete
Zoster can cause conjunctivitis, keratitis, uveitis, glaucoma and, rarely, retinal necrosis. Visual acuity documents her baseline and any change; fluorescein staining detects corneal involvement; pupil testing screens for deeper problems. A primary care examination cannot rule out uveitis or raised eye pressure, which require slit lamp examination and tonometry, the reason for same-day ophthalmology.
Why Antivirals Now
Antiviral therapy reduces viral replication, speeds healing and reduces acute pain, and guidelines recommend starting it within 72 hours of rash onset (Dworkin et al., 2007). The same recommendations advise antiviral treatment for zoster involving the eye even when patients present later, because of the risk to vision. Valacyclovir is preferred to acyclovir for convenience and better absorption. Mrs. B.'s kidney function is normal, so no dose adjustment is needed.
Why Steroids Are Not Started Here
Topical steroid eye drops are sometimes used for zoster-related inflammation, but they can worsen other eye infections and raise eye pressure; they should be started by ophthalmology after slit lamp examination, not in primary care.
Differential Diagnosis
Contact dermatitis, impetigo and herpes simplex can mimic zoster. The dermatomal band, preceding pain, sharp midline boundary and her age make zoster the clear diagnosis; herpes simplex keratitis would usually lack the dermatomal skin rash.
Examination Technique Notes
Several techniques in this examination are easy to omit. Visual acuity should be checked before instilling any drops, with glasses on, and recorded for each eye separately. Fluorescein should be applied with a moistened strip, and the cornea examined with a cobalt blue light; a branching, tree-like pattern of uptake suggests viral epithelial involvement. The nose should be inspected closely, including the tip and the side, since small vesicles there are easy to miss beneath the more obvious forehead rash. The examiner should wear gloves when touching lesions, since vesicle fluid contains virus.
Documentation Language
The note uses descriptive rather than diagnostic terms in the objective section: grouped vesicles on an erythematous base rather than a shingles rash, injected conjunctiva rather than pink eye. Descriptive language lets another clinician picture the findings and judge the diagnosis independently, and it avoids anchoring on a label before the assessment is written.
Diabetes and the Course of Zoster
Mrs. B.'s diabetes may slow healing and increase the risk of bacterial superinfection of the skin lesions. I will ask her to check her glucose more often during the illness, since pain and infection can raise it, and to watch for spreading redness or pus that would suggest a secondary skin infection.
Pain and Postherpetic Neuralgia
Older age and severe acute pain raise the risk of pain persisting after the rash heals. Early antivirals may reduce acute pain; persistent pain would be managed with agents such as gabapentin or topical lidocaine. I will ask about pain at follow-up.
Prevention
The recombinant zoster vaccine is recommended for adults 50 and older. Mrs. B. can receive it after recovery, to reduce the risk of recurrence.
Follow-Up
Mrs. B. will be called the next day to confirm she saw ophthalmology and started valacyclovir, and seen in one week to review healing, pain, glucose and any new eye symptoms, with a second visit after the rash has fully crusted.
Infection Control in the Clinic
The examination room was cleaned after the visit, and staff without immunity to varicella were kept from contact, since the fluid in open vesicles can transmit the virus to people who have never had chickenpox or its vaccine, causing chickenpox rather than shingles in them.
Conclusion
The note documents a left ophthalmic-division zoster with Hutchinson's sign, conjunctival injection, photophobia, reduced visual acuity and corneal staining. The nasal vesicles predicted eye involvement, the eye examination confirmed it and the plan followed: valacyclovir within 72 hours and same-day ophthalmology. Precise documentation of each finding made the urgency clear to the next clinician.
References
Cohen, J. I. (2013). Herpes zoster. New England Journal of Medicine, 369(3), 255-263. https://doi.org/10.1056/NEJMcp1302674
Dworkin, R. H., Johnson, R. W., Breuer, J., Gnann, J. W., Levin, M. J., Backonja, M., Betts, R. F., Gershon, A. A., Haanpää, M. L., McKendrick, M. W., Nurmikko, T. J., Oaklander, A. L., Oxman, M. N., Pavan-Langston, D., Petersen, K. L., Rowbotham, M. C., Schmader, K. E., Stacey, B. R., Tyring, S. K., . . . Whitley, R. J. (2007). Recommendations for the management of herpes zoster. Clinical Infectious Diseases, 44(Suppl. 1), S1-S26. https://doi.org/10.1086/510206
Zaal, M. J. W., Völker-Dieben, H. J., & D'Amaro, J. (2003). Prognostic value of Hutchinson's sign in acute herpes zoster ophthalmicus. Graefe's Archive for Clinical and Experimental Ophthalmology, 241(3), 187-191. https://doi.org/10.1007/s00417-002-0609-1
How this NRP 531 Week 3 example is structured
The NRP/531 Week 3 work usually asks for documentation of a skin or head, eyes, ears, nose and throat examination. This paper writes the note in SOAP form with precise descriptive language and then explains how the examination findings, especially one small lesion, changed the urgency of the plan. Students search this week as NRP 531 Week 3, NRP531 Wk 3 or NRP/531 Wk 3; all three are the same assignment.
NRP/531 Week 3 questions, answered
What does NRP/531 Week 3 usually ask for?
Many sections ask students to document a skin or HEENT examination with precise terminology and to connect findings to a diagnosis and plan.
What is Hutchinson's sign?
Vesicles on the tip, side or root of the nose in herpes zoster of the forehead, reflecting involvement of the nasociliary branch of the ophthalmic nerve, which also supplies the eye. It predicts eye involvement.
When should antivirals start for shingles?
Ideally within 72 hours of rash onset, and they are recommended for zoster involving the eye regardless of timing because of the risk to vision.
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