Rash
Comprehensive Guide + SOAP Note (Age 25)
� Patient Overview
Name: Sarah Mitchell
Age: 25 years
Gender: Female
Ethnicity: Caucasian (modifiable if needed)
Chief Complaint (CC):
“I have a rash that started a few days ago and it’s getting worse.”
� History of Present Illness (HPI)
Sarah Mitchell is a 25-year-old female presenting with a progressive rash that began
approximately 4–5 days ago.
Onset: Gradual
Location: Initially on forearms → spread to trunk and neck
,Duration: Persistent for 4–5 days
Characteristics:
Erythematous (red)
Pruritic (itchy)
Slightly raised patches
No vesicles or drainage
Aggravating factors:
Heat
Sweating
Relieving factors:
Mild relief with OTC antihistamines
Timing: Worse in the evening
Severity: 6/10 itching
Associated Symptoms:
Denies fever
Denies pain
Denies shortness of breath
, Denies recent illness
Relevant Exposure History:
Recently started using a new body lotion/perfume
No recent travel
No sick contacts
No new medications
� Past Medical History (PMH)
No chronic illnesses
No history of eczema or psoriasis
No autoimmune disorders
� Medications
Occasional OTC antihistamines (e.g., cetirizine)
Allergies
No known drug allergies (NKDA)