i-Human Graduate Sick Visit Case Study Week #4
(2026): 13-Year-Old Female With Pruritic Skin
Complaint – Comprehensive Clinical Reasoning Guide
With Full Patient Interview, ROS, Focused Physical
Exam, Differential Diagnoses, Laboratory Evaluation,
Final Diagnosis, Treatment Strategy, and Patient
Counseling
,SOAP NOTE — i-Human Graduate Sick
Visit Case Study
Patient Name:
Age: 13 years
Sex: Female
Date of Encounter: [Current Date]
Location: Outpatient Clinic
Reason for Encounter: Pruritic skin rash
S (Subjective)
● Chief Complaint: "I've been itching all over. This rash keeps me up at
night."
● History of Present Illness (HPI): The patient is a 13-year-old female
presenting with a chief complaint of a pruritic skin rash. The rash
began approximately [number] days/weeks ago. She reports that the
rash initially appeared on the [location] and has since [spread to /
remained localized to] the [areas involved]. She describes the rash as:
○ Morphology: [Red bumps / raised welts / dry patches / scaly
plaques / fluid-filled blisters]
○ Distribution: [Localized / generalized / flexural (elbows, knees) /
extensor / trunk / extremities]
○ Itching: [Mild / moderate / severe] — reports itching [constant /
worse at night / worse after bathing / worse with stress]
, ○ Onset: [Sudden / gradual]
○ Course: [Constant / intermittent / improving / worsening]
● Aggravating factors: [Heat, sweating, stress, certain fabrics, soaps,
lotions, food, exercise]
● Alleviating factors: [Cool compresses, antihistamines, moisturizers,
avoidance of triggers]
● Associated symptoms:
○ Systemic: Denies fever, chills, malaise, joint pain, swollen lymph
nodes
○ Respiratory: Denies cough, wheezing, shortness of breath —
important for allergic etiology
○ Gastrointestinal: Denies nausea, vomiting, diarrhea, abdominal
pain
○ Constitutional: Denies weight loss, night sweats
● Treatments attempted: Has tried [over-the-counter hydrocortisone
cream, antihistamines (diphenhydramine, cetirizine), moisturizers,
oatmeal baths] with [minimal / moderate / no] relief.
● Previous episodes: [Denies prior episodes / history of eczema, hives,
or allergies]
● Past Medical History (PMH):
○ Atopic history: [History of eczema, asthma, allergic rhinitis, food
allergies] — critical for atopic dermatitis
○ Skin conditions: [Prior rashes, psoriasis, hives]
○ Other: [No chronic medical conditions]
● Past Surgical History (PSH): None
● Medications:
○ Prescription: [None / list any medications]
○ Over-the-counter: [Antihistamines, topical creams,
supplements]
○ New medications in past 30 days: [Any antibiotics, NSAIDs,
anticonvulsants — important for drug eruption]
● Allergies:
○ Medication allergies: [None / specify]
(2026): 13-Year-Old Female With Pruritic Skin
Complaint – Comprehensive Clinical Reasoning Guide
With Full Patient Interview, ROS, Focused Physical
Exam, Differential Diagnoses, Laboratory Evaluation,
Final Diagnosis, Treatment Strategy, and Patient
Counseling
,SOAP NOTE — i-Human Graduate Sick
Visit Case Study
Patient Name:
Age: 13 years
Sex: Female
Date of Encounter: [Current Date]
Location: Outpatient Clinic
Reason for Encounter: Pruritic skin rash
S (Subjective)
● Chief Complaint: "I've been itching all over. This rash keeps me up at
night."
● History of Present Illness (HPI): The patient is a 13-year-old female
presenting with a chief complaint of a pruritic skin rash. The rash
began approximately [number] days/weeks ago. She reports that the
rash initially appeared on the [location] and has since [spread to /
remained localized to] the [areas involved]. She describes the rash as:
○ Morphology: [Red bumps / raised welts / dry patches / scaly
plaques / fluid-filled blisters]
○ Distribution: [Localized / generalized / flexural (elbows, knees) /
extensor / trunk / extremities]
○ Itching: [Mild / moderate / severe] — reports itching [constant /
worse at night / worse after bathing / worse with stress]
, ○ Onset: [Sudden / gradual]
○ Course: [Constant / intermittent / improving / worsening]
● Aggravating factors: [Heat, sweating, stress, certain fabrics, soaps,
lotions, food, exercise]
● Alleviating factors: [Cool compresses, antihistamines, moisturizers,
avoidance of triggers]
● Associated symptoms:
○ Systemic: Denies fever, chills, malaise, joint pain, swollen lymph
nodes
○ Respiratory: Denies cough, wheezing, shortness of breath —
important for allergic etiology
○ Gastrointestinal: Denies nausea, vomiting, diarrhea, abdominal
pain
○ Constitutional: Denies weight loss, night sweats
● Treatments attempted: Has tried [over-the-counter hydrocortisone
cream, antihistamines (diphenhydramine, cetirizine), moisturizers,
oatmeal baths] with [minimal / moderate / no] relief.
● Previous episodes: [Denies prior episodes / history of eczema, hives,
or allergies]
● Past Medical History (PMH):
○ Atopic history: [History of eczema, asthma, allergic rhinitis, food
allergies] — critical for atopic dermatitis
○ Skin conditions: [Prior rashes, psoriasis, hives]
○ Other: [No chronic medical conditions]
● Past Surgical History (PSH): None
● Medications:
○ Prescription: [None / list any medications]
○ Over-the-counter: [Antihistamines, topical creams,
supplements]
○ New medications in past 30 days: [Any antibiotics, NSAIDs,
anticonvulsants — important for drug eruption]
● Allergies:
○ Medication allergies: [None / specify]
