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,iHuman Case Study Week 2 – Victoria Lewis Comprehensive
SOAP Note and Diagnostic Evaluation 25-Year-Old Female
with New-Onset Pruritic Vesicular Rash (May 2025)
Full Patient Introduction – Victoria Lewis
Patient Name: Victoria Lewis
Age: 25 years old
Gender: Female
Ethnicity: Caucasian
Marital Status: Single
Occupation: Graduate student / office worker (varies slightly by course
version)
Chief Complaint: “I have a new itchy rash that keeps spreading.”
History of Present Illness (HPI)
Victoria Lewis is a 25-year-old female who presents with a complaint of
a new rash that began approximately 2–3 days ago after participating in
outdoor activities/hiking. She reports that the rash initially started on
her forearms and later spread to her legs and other exposed skin areas.
The rash is intensely pruritic and associated with redness and small
fluid-filled blisters.
She denies fever, chills, shortness of breath, facial swelling, oral lesions,
nausea, vomiting, or recent illness. She reports no previous episodes of
, a similar rash. She recently used a new laundry detergent and spent
time outdoors in wooded areas prior to symptom onset.
The patient states that scratching worsens the rash and itching. Over-
the-counter creams have provided minimal relief.
Past Medical History
• No significant chronic medical conditions
• No history of eczema or psoriasis
• Immunizations up to date
Surgical History
• No significant surgical history reported
Medications
• Occasional OTC antihistamines or topical anti-itch cream
Allergies
• No known drug allergies (NKDA)
Family History
• Noncontributory
• No significant family history of autoimmune or dermatologic
disorders
,iHuman Case Study Week 2 – Victoria Lewis Comprehensive
SOAP Note and Diagnostic Evaluation 25-Year-Old Female
with New-Onset Pruritic Vesicular Rash (May 2025)
Full Patient Introduction – Victoria Lewis
Patient Name: Victoria Lewis
Age: 25 years old
Gender: Female
Ethnicity: Caucasian
Marital Status: Single
Occupation: Graduate student / office worker (varies slightly by course
version)
Chief Complaint: “I have a new itchy rash that keeps spreading.”
History of Present Illness (HPI)
Victoria Lewis is a 25-year-old female who presents with a complaint of
a new rash that began approximately 2–3 days ago after participating in
outdoor activities/hiking. She reports that the rash initially started on
her forearms and later spread to her legs and other exposed skin areas.
The rash is intensely pruritic and associated with redness and small
fluid-filled blisters.
She denies fever, chills, shortness of breath, facial swelling, oral lesions,
nausea, vomiting, or recent illness. She reports no previous episodes of
, a similar rash. She recently used a new laundry detergent and spent
time outdoors in wooded areas prior to symptom onset.
The patient states that scratching worsens the rash and itching. Over-
the-counter creams have provided minimal relief.
Past Medical History
• No significant chronic medical conditions
• No history of eczema or psoriasis
• Immunizations up to date
Surgical History
• No significant surgical history reported
Medications
• Occasional OTC antihistamines or topical anti-itch cream
Allergies
• No known drug allergies (NKDA)
Family History
• Noncontributory
• No significant family history of autoimmune or dermatologic
disorders
