Pamela is a 33-year-old female here today with complaints of a cold sore.
HPI
The patient tells me she has never had a cold sore before, but her husband gets them and she has seen lots of them on him. She said that she noticed yesterday along the left side of the upper lip, a little bit of tingling when she pressed on that area. It felt a little bit firm and tender. Her husband also noticed the red bump there as well. She is worried because she thinks it might be a herpes outbreak. As mentioned, her husband has oral herpes. He does not have a history of genital herpes nor does she. She has never had anything like this prior. She does get canker sores, however occasionally. She said yesterday she had more goose bumps than normal, …show more content…
No anterior or posterior cervical lymphadenopathy.
Skin
Examination around the mouth does show a small, erythematous papule just to the left side of the upper lip. There is no obvious ulceration. There is no surrounding redness. There is no drainage noted. She describes a little bit of tenderness to touch.
A/P
Pamela Peavey is a 33-year-old female here today with a skin lesion just above her left upper lip. We did discuss that it did not have the typical vesicular, crusted, or umbilicated lesion that we sometimes will see as herpes lesions progress. However, as we are heading to the weekend and I cannot confirm that it is not and she definitely has the exposure and with the tenderness and tingling, I have written her for Zovirax cream to be applied five times daily for four days. We briefly discussed HSV in the office. Education was provided. She does understand that it can be contagious. I have recommended that if she continues to have outbreaks down the road, we can discuss other therapies including avoidance of her triggers as well as potential oral medication. Today, however that was not given. She knows to contact me if she has further questions or concerns. She did receive her flu shot per her request here today in the
HPI
The patient tells me she has never had a cold sore before, but her husband gets them and she has seen lots of them on him. She said that she noticed yesterday along the left side of the upper lip, a little bit of tingling when she pressed on that area. It felt a little bit firm and tender. Her husband also noticed the red bump there as well. She is worried because she thinks it might be a herpes outbreak. As mentioned, her husband has oral herpes. He does not have a history of genital herpes nor does she. She has never had anything like this prior. She does get canker sores, however occasionally. She said yesterday she had more goose bumps than normal, …show more content…
No anterior or posterior cervical lymphadenopathy.
Skin
Examination around the mouth does show a small, erythematous papule just to the left side of the upper lip. There is no obvious ulceration. There is no surrounding redness. There is no drainage noted. She describes a little bit of tenderness to touch.
A/P
Pamela Peavey is a 33-year-old female here today with a skin lesion just above her left upper lip. We did discuss that it did not have the typical vesicular, crusted, or umbilicated lesion that we sometimes will see as herpes lesions progress. However, as we are heading to the weekend and I cannot confirm that it is not and she definitely has the exposure and with the tenderness and tingling, I have written her for Zovirax cream to be applied five times daily for four days. We briefly discussed HSV in the office. Education was provided. She does understand that it can be contagious. I have recommended that if she continues to have outbreaks down the road, we can discuss other therapies including avoidance of her triggers as well as potential oral medication. Today, however that was not given. She knows to contact me if she has further questions or concerns. She did receive her flu shot per her request here today in the