COMPREHENSIVE IHUMAN WEEK #2 CASE STUDY: 25 YEARS OLD FEMALE WITH A SKIN NEW RASH FULL SOAP NOTE | BRAND NEW VERSION

COMPREHENSIVE IHUMAN WEEK #2 CASE STUDY: 25
YEARS OLD FEMALE WITH A SKIN NEW RASH FULL SOAP
NOTE | BRAND NEW VERSION

,PART 1: PATIENT BIO DATA & INITIAL DATA GATHERING

Category Details

Age 25 years old

Gender Female

Height 165 cm (5'5")

Weight 54.5 kg (120 lbs)

BMI 20.0 kg/m² (Normal range: 18.5-24.9)

Source Patient (self)

Reliability Reliable, alert, and able to provide clear history

Allergies No Known Drug Allergies (NKDA)

Chief Complaint: "I have a new rash."
Encounter Type: Outpatient clinic visit for rash evaluation


PART 2: PAST MEDICAL HISTORY (PMH)

Condition Details

No significant past medical
Presumed healthy
history

Previous skin conditions None reported

Allergies None known

, Condition Details

Autoimmune disorders None known

Must ask: URI symptoms, fever, sore throa
Recent illnesses
in past weeks

Medication history Any new medications prior to rash onset?

Key Questions to Ask:

 Any prior history of rash or skin conditions?
 Any known allergies (medications, foods, environmental)?
 Any recent infections (upper respiratory, strep throat, viral
illness)?
 Any chronic medical conditions (autoimmune, thyroid, etc.)?


PART 3: PAST SURGICAL HISTORY (PSH)

Surgery Details

None reported No prior surgical history


PART 4: MEDICATIONS

Current Medications

Medication Dose Frequency Prescriber Purpose

None N/A N/A N/A N/A


Key Medication Questions

,  Any new medications started in past 4-6 weeks? (Critical for
drug eruption diagnosis)
 Any over-the-counter medications, supplements, or herbal
remedies?
 Any antibiotics recently (amoxicillin, penicillins, sulfa drugs)?
 Any NSAIDs (ibuprofen, naproxen)?
 Oral contraceptives?


PART 5: FAMILY HISTORY

Relative Age/Status Medical Conditions

Mother [Age] [Any skin conditions? Autoimmune disease?]

Father [Age] [Any skin conditions?]

Siblings [Ages] [Any skin conditions?]


Key Family History Questions

 Any family history of psoriasis, eczema, or other skin disorders?
 Any family history of autoimmune diseases (lupus, rheumatoid
arthritis, thyroid disease)?
 Any family history of allergies or atopy (asthma, allergic rhinitis,
eczema)?


PART 6: SOCIAL HISTORY

Factor Details

Occupation Must ask – possible occupational exposures

Living Situation Lives alone/with family/with roommates