I HUMAN CASE STUDY # WEEK 2 36 YEAR OLD REASON
FOR ENCOUNTER ITCHY RASH WITH A FULL SOAP NOTE
ACTUAL !!! 2025
, HISTORY
Chief Complaint (CC):
“Itchy rash.”
History of Present Illness (HPI):
The patient is a 36-year-old adult who presents with a 5-day history of a progressively worsening itchy
rash. The rash initially appeared on the forearms and has since spread to the chest and neck. It is
described as red, raised, and very pruritic, especially at night.
The patient denies pain, burning, or blistering. Reports mild relief with OTC hydrocortisone but
symptoms return quickly. Denies new medications.
Recent exposures include:
• New laundry detergent started 1 week ago
• Outdoor hiking 2 days before the rash started
• No recent travel, no sick contacts
No known insect bites. No similar symptoms in household members.
Denies fever, malaise, joint pains, sore throat, shortness of breath, lip swelling, nausea, vomiting, or
diarrhea.
No prior episodes of a similar rash.
Pertinent Negatives:
• No facial swelling
• No wheezing
• No new foods or medications
• No history of eczema or psoriasis
• No recent illness
Past Medical History (PMH):
• Seasonal allergies
• No history of asthma, eczema, autoimmune diseases, or skin conditions
Past Surgical History (PSH):
• None significant
Medications:
FOR ENCOUNTER ITCHY RASH WITH A FULL SOAP NOTE
ACTUAL !!! 2025
, HISTORY
Chief Complaint (CC):
“Itchy rash.”
History of Present Illness (HPI):
The patient is a 36-year-old adult who presents with a 5-day history of a progressively worsening itchy
rash. The rash initially appeared on the forearms and has since spread to the chest and neck. It is
described as red, raised, and very pruritic, especially at night.
The patient denies pain, burning, or blistering. Reports mild relief with OTC hydrocortisone but
symptoms return quickly. Denies new medications.
Recent exposures include:
• New laundry detergent started 1 week ago
• Outdoor hiking 2 days before the rash started
• No recent travel, no sick contacts
No known insect bites. No similar symptoms in household members.
Denies fever, malaise, joint pains, sore throat, shortness of breath, lip swelling, nausea, vomiting, or
diarrhea.
No prior episodes of a similar rash.
Pertinent Negatives:
• No facial swelling
• No wheezing
• No new foods or medications
• No history of eczema or psoriasis
• No recent illness
Past Medical History (PMH):
• Seasonal allergies
• No history of asthma, eczema, autoimmune diseases, or skin conditions
Past Surgical History (PSH):
• None significant
Medications:
