iHuman Case : Victoria Lewis – 25 y/o
Female with New Rashes" | Complete
Diagnosis & SOAP Notes | MAY 2025 CASE
STUDY
Patient Name: Victoria Lewis
Age: 25 years
Sex: Female
Chief Complaint (CC): "I have a new rash that just showed up a few days ago."
, SOAP Note: Victoria Lewis
S – Subjective
CC: “I’ve developed a red, itchy rash on my arms and legs over the past 3 days.”
HPI (History of Present Illness):
Victoria Lewis is a 25-year-old female presenting with a pruritic (itchy), erythematous (red) rash that
began 3 days ago. The rash initially appeared on her forearms and has since spread to her legs. She
denies fever, chills, sore throat, or recent illnesses. No new soaps or detergents but reports starting a
new antibiotic (amoxicillin) 4 days ago for a sinus infection. She reports no history of similar rashes in
the past. She also mentions mild fatigue but no other systemic symptoms.
PMH (Past Medical History):
• Allergic rhinitis
• Recent sinusitis, treated with amoxicillin
Medications:
• Amoxicillin (started 4 days ago)
• Cetirizine (as needed for allergies)
Allergies:
• NKDA (no known drug allergies) reported, but suspect reaction now
FH (Family History):
• Non-contributory
SH (Social History):
• Non-smoker
• Social alcohol use
• Lives alone
• Works as a graphic designer
ROS (Review of Systems):
• Skin: Rash, pruritus
• Constitutional: Mild fatigue
• HEENT: No fever, no sore throat
• Respiratory: No shortness of breath
Female with New Rashes" | Complete
Diagnosis & SOAP Notes | MAY 2025 CASE
STUDY
Patient Name: Victoria Lewis
Age: 25 years
Sex: Female
Chief Complaint (CC): "I have a new rash that just showed up a few days ago."
, SOAP Note: Victoria Lewis
S – Subjective
CC: “I’ve developed a red, itchy rash on my arms and legs over the past 3 days.”
HPI (History of Present Illness):
Victoria Lewis is a 25-year-old female presenting with a pruritic (itchy), erythematous (red) rash that
began 3 days ago. The rash initially appeared on her forearms and has since spread to her legs. She
denies fever, chills, sore throat, or recent illnesses. No new soaps or detergents but reports starting a
new antibiotic (amoxicillin) 4 days ago for a sinus infection. She reports no history of similar rashes in
the past. She also mentions mild fatigue but no other systemic symptoms.
PMH (Past Medical History):
• Allergic rhinitis
• Recent sinusitis, treated with amoxicillin
Medications:
• Amoxicillin (started 4 days ago)
• Cetirizine (as needed for allergies)
Allergies:
• NKDA (no known drug allergies) reported, but suspect reaction now
FH (Family History):
• Non-contributory
SH (Social History):
• Non-smoker
• Social alcohol use
• Lives alone
• Works as a graphic designer
ROS (Review of Systems):
• Skin: Rash, pruritus
• Constitutional: Mild fatigue
• HEENT: No fever, no sore throat
• Respiratory: No shortness of breath
