History

Presenting features

Zoster symptom characterization

OPQRST

Onset

Provocation and palliation

Quality

Region and radiation

Severity

Timing

Associated symptoms

Systemic and focal symptoms

Alarm Features

Immediate escalation triggers

High risk presentations

Vital signs and toxicity

Concerning physiologic features

High risk exam findings

Exam red flags

Medications

Current and recent exposures

Medication review

Analgesic and neuropathic agents

Current symptom treatments

Contraindications and interactions

Key medication safety checks

Diet

Hydration and intake

Current intake status

Potential modifiers

Exposures that worsen symptoms

Review of Systems

Skin and lymphatic

Skin findings

Eye and ENT

Eye and ear symptoms

Neuro and systemic

Neuro systemic symptoms

Collateral History and Family History

Collateral and reliability

Context and supports

Family history and host factors

Familial risk context

Risk Factors

Immunocompromise and host risk

Conditions increasing risk and severity

Exposure and transmission context

Contact risk considerations

Special populations

Higher stakes groups

Differential Diagnosis

Life threatening

Cannot miss diagnoses

Common

Frequent alternatives

Less common and mimics

Mimics and pitfalls

Past Medical History

Relevant conditions

Host and prior events

Procedures and devices

Recent healthcare exposures

Physical Exam

General and vitals

Global assessment

Skin exam

Rash characterization

Eye and ENT exam

Face and sensory nerve distributions

Neuro exam

Neurologic screen

Lab Studies

When diagnosis uncertain or severe disease

Targeted labs

CNS complication workup

If meningitis or encephalitis concern

Test limitations

Practical pitfalls

Imaging

Scoring Systems

Decision support for complications

MRI

Neuro imaging indications

CT

Acute neuro screening

Ultrasound

Limited role

Special Tests

Virologic confirmation

Lesion based testing

Eye and ENT focused testing

Specialty evaluation triggers

ECG

When to obtain

Indications

High risk patterns

ECG red flags

Assessment

Working diagnosis

Primary considerations

Severity stratification

Higher risk features

Key supporting features

Clinical support

Plan

First 5 minutes and safety checks

Immediate priorities

Antiviral therapy

Antivirals

Pain control and symptom management

Analgesia ladder

Adjuncts

Complication specific management

Ophthalmic involvement

Ramsay Hunt concern

Suspected bacterial superinfection

Reassessment loop

Time based reassessment

Disposition

Admission and higher level care

Admit criteria

ICU criteria

Observation pathway

Observation considerations

Discharge criteria and follow up

Safe discharge features

Follow up timing

Discharge Instructions

Copy discharge instructions

Diagnosis

Medications

Skin care and infection control

Activity

Follow up

Return to ED now if

References

Guidelines and key sources

CDC shingles clinical overview 2024

ACIP recombinant zoster vaccine recommendations 2022

American Academy of Ophthalmology herpes zoster ophthalmicus guidance 2023

IDSA clinical practice guidance for management of VZV in immunocompromised hosts 2019

Cochrane review antivirals for acute herpes zoster 2014

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.