Case23

Background

A 72-year-old handicrafts teacher. Recently widowed, Mother of 2 children and grandmother of 4.
She has been diagnosed with a number of chronic health problems over the last several years and is currently receiving treatment for hypertension, osteoarthritis, and chronic obstructive pulmonary disease (COPD).
Despite her doctor's advice, she has found it difficult to lose weight and quit smoking.
Today, her medical status is:
Height: 5'5"; weight:184 lbs; BMI: 30.6 kg/m2
BP: 141/89 mm Hg
Lungs: clear to percussion, but mild wheezing bilaterally
For hypertension: lisinopril 10 mg/hydrochlorothiazide 12.5 mg daily.
For osteoarthritis of the knee: naproxen sodium 375 mg twice daily.
For COPD: fluticasone propionate 100 mcg/albuterol 50 mcg inhalation powder once daily.
Presenting symptoms:
Severe, persistent throbbing pain in the right chest wall, extending from the back to the nipple line.
Pain began with an attack of herpes zoster (HZ) 2 years ago; pain continued through course of acyclovir therapy and persisted after healing of the rash.
Examination reveals an area that is extremely sensitive to light touch within and outside the affected dermatome.
There is some scarring at the site.
she describes her pain as continuous–"like a deep burn" with episodes of sensations that feel like an electric shock

• Which of the following are the most reliable types of information to
  diagnose the cause of her pain?

The correct answer is 'd' comprehensive and focused patient history and imaging studies.