Past Encounter
On birth control, daily pill, sexually active with 1 male partner, no Hx of
STIs, gets regular PAPs (negative results).
Denies tobacco or drug use, reports occasional alcohol use
Allergies: Ceclor (Cefaclor) reports hives as a child
Preventative health: annual physicals, dental check ups every 6
months, annual Pap smears, last test negative for dysplasia or other
changes.
All childhood immunizations up to date, HPV13 received, annual
influenza vaccine received, completed COVD 19 vaccines
FHx: mother 58, alive and well, father 59 HTN, sister 21 alive and well,
bothers 25 and 32 alive and well, maternal grandfather died at 81 Hx
of CVD, maternal grandmother 88 HTN, Hx of MI with stent placement
Tobacco: denies
Alcohol: 2-3 5 oz glasses of wine on weekends, CAGE 0/4
Drug: Denies
Activity: runs 3 times per week. Bikes to work daily, loves to go dancing
Stressors: denies any major stressors
Living situation: lives alone, stable housing
Support system: support from family and bf
Occupation: education degree, looking for a teaching job
Safety: wears helmet when she bikes
Sexual Hx: sexually active with one male partner, uses oral
contraceptive pills
CV: RRR, no murmur or gallop
Key Findings
Exposed to poison ivy/oak/sumac? Cant be 100%, what all we walked
though while we were bushwacking, I think that area has stuff like that
growing on those hills
Exposed to mosquitos and bites
Denies fever, chills and night sweats
Denies being SOB
Denies N/V
Went to napa with bs since then noticed 2 rashes that look li ke sores
that began 2 days ago, got in hot tub after hiking, used bf new sun tan
lotion, has not tried anything to make it better, really uncomfortable,
itchy and tender, maybe from all the scratching, started in thighs now
on left inner forearm
This study source was downloaded by 100000895165518 from CourseHero.com on 01-02-2025 07:18:04 GMT -06:00
https://www.coursehero.com/file/243429839/Krista-Hampton-SOAP-notedocx/
, No current or past medical problems
Goes to dentist regularly
No hospitalizations
Meds: birthcontrol, does not remember name, no other OTC meds, not
having any problems with current medications
Allergies: Cefaclor gave rash when given as a child
Normal PAP
Living by herself in apt
College degree
Occupation: English teacher grades 7 and 8
Drinks socially CAGE 0/4
Denies recreation drugs, injection IV drugs and chewed and smoked
tobacco
Ordered scallops for first time on getaway
Sexually active with bf only, sometimes use condoms
PE
Weight 120lbs, temp 98.6 F, P 76 regular normal, BP left 116/62, RR 12
regular unlabored, SpO2 98%
INT: inner forearm rash measurement 6cm linear; thigh rash
measurement 10 x 12 cm/ bilateral inner thighs with 10 x 12 cm raised
confluent, erythematous papules and blisters in various stages, left
ventral forearm with 6 cm linear erythematous papules and yellow-red
blisters.
Thyroid: mobile without masses, tenderness, nodules, or enlargement
CV: carotid arteries without buits
Problem statement: K.H is a 25 year old Caucasian female presenting with an
itchy and tender rash bilaterally on her inner thighs that radiated to her inner
left forearm. The rash developed about 2 days ago after hiking in Napa with
her boyfriend. She has not tried anything to make it better and is not sure if
anything makes it worse but did notice it is spreading. She is not sure if she
ran into any poison ivy but states she would not be surprised if there was
some on the hiking trail. K.H states that during her time hiking, she tried a
new suntan and new foods such as scallops. She also reports spending time
in the hot tub with her boyfriend. The boyfriend does not have similar
symptoms.
This study source was downloaded by 100000895165518 from CourseHero.com on 01-02-2025 07:18:04 GMT -06:00
https://www.coursehero.com/file/243429839/Krista-Hampton-SOAP-notedocx/
On birth control, daily pill, sexually active with 1 male partner, no Hx of
STIs, gets regular PAPs (negative results).
Denies tobacco or drug use, reports occasional alcohol use
Allergies: Ceclor (Cefaclor) reports hives as a child
Preventative health: annual physicals, dental check ups every 6
months, annual Pap smears, last test negative for dysplasia or other
changes.
All childhood immunizations up to date, HPV13 received, annual
influenza vaccine received, completed COVD 19 vaccines
FHx: mother 58, alive and well, father 59 HTN, sister 21 alive and well,
bothers 25 and 32 alive and well, maternal grandfather died at 81 Hx
of CVD, maternal grandmother 88 HTN, Hx of MI with stent placement
Tobacco: denies
Alcohol: 2-3 5 oz glasses of wine on weekends, CAGE 0/4
Drug: Denies
Activity: runs 3 times per week. Bikes to work daily, loves to go dancing
Stressors: denies any major stressors
Living situation: lives alone, stable housing
Support system: support from family and bf
Occupation: education degree, looking for a teaching job
Safety: wears helmet when she bikes
Sexual Hx: sexually active with one male partner, uses oral
contraceptive pills
CV: RRR, no murmur or gallop
Key Findings
Exposed to poison ivy/oak/sumac? Cant be 100%, what all we walked
though while we were bushwacking, I think that area has stuff like that
growing on those hills
Exposed to mosquitos and bites
Denies fever, chills and night sweats
Denies being SOB
Denies N/V
Went to napa with bs since then noticed 2 rashes that look li ke sores
that began 2 days ago, got in hot tub after hiking, used bf new sun tan
lotion, has not tried anything to make it better, really uncomfortable,
itchy and tender, maybe from all the scratching, started in thighs now
on left inner forearm
This study source was downloaded by 100000895165518 from CourseHero.com on 01-02-2025 07:18:04 GMT -06:00
https://www.coursehero.com/file/243429839/Krista-Hampton-SOAP-notedocx/
, No current or past medical problems
Goes to dentist regularly
No hospitalizations
Meds: birthcontrol, does not remember name, no other OTC meds, not
having any problems with current medications
Allergies: Cefaclor gave rash when given as a child
Normal PAP
Living by herself in apt
College degree
Occupation: English teacher grades 7 and 8
Drinks socially CAGE 0/4
Denies recreation drugs, injection IV drugs and chewed and smoked
tobacco
Ordered scallops for first time on getaway
Sexually active with bf only, sometimes use condoms
PE
Weight 120lbs, temp 98.6 F, P 76 regular normal, BP left 116/62, RR 12
regular unlabored, SpO2 98%
INT: inner forearm rash measurement 6cm linear; thigh rash
measurement 10 x 12 cm/ bilateral inner thighs with 10 x 12 cm raised
confluent, erythematous papules and blisters in various stages, left
ventral forearm with 6 cm linear erythematous papules and yellow-red
blisters.
Thyroid: mobile without masses, tenderness, nodules, or enlargement
CV: carotid arteries without buits
Problem statement: K.H is a 25 year old Caucasian female presenting with an
itchy and tender rash bilaterally on her inner thighs that radiated to her inner
left forearm. The rash developed about 2 days ago after hiking in Napa with
her boyfriend. She has not tried anything to make it better and is not sure if
anything makes it worse but did notice it is spreading. She is not sure if she
ran into any poison ivy but states she would not be surprised if there was
some on the hiking trail. K.H states that during her time hiking, she tried a
new suntan and new foods such as scallops. She also reports spending time
in the hot tub with her boyfriend. The boyfriend does not have similar
symptoms.
This study source was downloaded by 100000895165518 from CourseHero.com on 01-02-2025 07:18:04 GMT -06:00
https://www.coursehero.com/file/243429839/Krista-Hampton-SOAP-notedocx/
