Katherine Moore: 66-Year-Old Female with a Painful Rash
(Herpes Zoster) Integument Application: Unilateral Painful
Rash in an Older Adult Case Study
, 1. Full Clinical Case Scenario
Case Title: Integument: Application - Katherine Moore
Setting: Outpatient Primary Care Clinic / Urgent Care
Patient Profile:
• Name: Katherine Moore
• Age/Gender: 66-year-old Female
• Marital Status: Widowed
• Demographics: White, English-speaking
• Vitals: 5'4", 145 lb
• Allergies: Penicillin (Rash), Aspirin (Congestion)
• Chief Complaint: Painful Rash
History of Present Illness (HPI):
Mrs. Moore presents to the clinic today complaining of a painful rash on her left torso that
began 3 days ago. She describes the initial sensation as a "burning, tingling, and sharp shooting
pain" under her left ribcage. Yesterday, she noticed a red, blistery rash developing in the same
area. The pain is severe enough to disrupt her sleep and daily activities. She denies any recent
trauma, new soaps, detergents, or changes in diet. She has not taken anything for the pain due
to her aspirin allergy. She reports feeling slightly fatigued and has a low-grade fever (100.1°F)
but denies chills, nausea, or shortness of breath.
Past Medical History (PMH): Hypertension, Hyperlipidemia, Osteoarthritis.
Medications: Lisinopril 10mg daily, Atorvastatin 20mg daily.
Social History: Widowed 2 years ago. Lives alone. Retired teacher. Denies tobacco, alcohol, or
illicit drug use.
2. SOAP Note
SUBJECTIVE:
(Herpes Zoster) Integument Application: Unilateral Painful
Rash in an Older Adult Case Study
, 1. Full Clinical Case Scenario
Case Title: Integument: Application - Katherine Moore
Setting: Outpatient Primary Care Clinic / Urgent Care
Patient Profile:
• Name: Katherine Moore
• Age/Gender: 66-year-old Female
• Marital Status: Widowed
• Demographics: White, English-speaking
• Vitals: 5'4", 145 lb
• Allergies: Penicillin (Rash), Aspirin (Congestion)
• Chief Complaint: Painful Rash
History of Present Illness (HPI):
Mrs. Moore presents to the clinic today complaining of a painful rash on her left torso that
began 3 days ago. She describes the initial sensation as a "burning, tingling, and sharp shooting
pain" under her left ribcage. Yesterday, she noticed a red, blistery rash developing in the same
area. The pain is severe enough to disrupt her sleep and daily activities. She denies any recent
trauma, new soaps, detergents, or changes in diet. She has not taken anything for the pain due
to her aspirin allergy. She reports feeling slightly fatigued and has a low-grade fever (100.1°F)
but denies chills, nausea, or shortness of breath.
Past Medical History (PMH): Hypertension, Hyperlipidemia, Osteoarthritis.
Medications: Lisinopril 10mg daily, Atorvastatin 20mg daily.
Social History: Widowed 2 years ago. Lives alone. Retired teacher. Denies tobacco, alcohol, or
illicit drug use.
2. SOAP Note
SUBJECTIVE:
