,i-Human Case Study
13-Year-Old Female – Chief Complaint: Itchy Skin
(Pruritus)
1. Identifying Information
• Name: [Patient Initials]
• Age: 13 years
• Sex: Female
• Source: Patient + parent (reliable)
2. Chief Complaint (CC)
“My skin has been really itchy for the past few weeks.”
3. History of Present Illness (HPI)
13-year-old female presents with generalized itching for ~2–4 weeks.
Use OLDCARTS framework:
• Onset: Gradual
• Location: Initially arms → now generalized (arms, legs, trunk)
• Duration: Persistent, worse at night
• Character: Intense itching, sometimes burning after scratching
• Aggravating factors: Heat, sweating, nighttime
• Relieving factors: Temporary relief with scratching or cool showers
• Timing: Worse at night
• Severity: 7/10
Associated Symptoms:
• Rash (yes/no depending on case variation)
• Dry skin
• Excoriations from scratching
• Possible sleep disturbance
Pertinent Negatives:
, • No fever
• No weight loss
• No jaundice
• No recent illness
• No new medications (or specify if present)
4. Past Medical History (PMH)
• Possible history of:
o Atopic dermatitis (eczema)
o Allergies (seasonal, food)
• No chronic systemic illness
5. Medications
• OTC creams or antihistamines (if used)
• No new medications (important for drug reaction)
6. Allergies
• NKDA or specify (e.g., soaps, detergents, foods)
7. Family History
• Atopy (eczema, asthma, allergic rhinitis)
• Skin conditions
8. Social History
• Lives with family
• School-going
• Hygiene habits
• Possible exposure:
o New soaps/detergents
o Pets
o Close contacts with similar symptoms (important for scabies)
, 9. Review of Systems (ROS)
Positive:
• Skin: itching, dryness, rash
Negative:
• Constitutional: no fever, fatigue
• GI: no abdominal pain
• Hepatic: no jaundice
• Endocrine: no heat/cold intolerance
10. Physical Examination
Vitals
• Normal
General
• Alert, mildly uncomfortable due to itching
Skin
Findings depend on diagnosis but may include:
• Dry, scaly skin
• Erythematous patches
• Excoriations
• Possible:
o Flexural involvement → eczema
o Burrows/web spaces → scabies
o Urticarial wheals → allergy
Other Systems
• Normal (important to rule out systemic disease)
Differential Diagnosis
13-Year-Old Female – Chief Complaint: Itchy Skin
(Pruritus)
1. Identifying Information
• Name: [Patient Initials]
• Age: 13 years
• Sex: Female
• Source: Patient + parent (reliable)
2. Chief Complaint (CC)
“My skin has been really itchy for the past few weeks.”
3. History of Present Illness (HPI)
13-year-old female presents with generalized itching for ~2–4 weeks.
Use OLDCARTS framework:
• Onset: Gradual
• Location: Initially arms → now generalized (arms, legs, trunk)
• Duration: Persistent, worse at night
• Character: Intense itching, sometimes burning after scratching
• Aggravating factors: Heat, sweating, nighttime
• Relieving factors: Temporary relief with scratching or cool showers
• Timing: Worse at night
• Severity: 7/10
Associated Symptoms:
• Rash (yes/no depending on case variation)
• Dry skin
• Excoriations from scratching
• Possible sleep disturbance
Pertinent Negatives:
, • No fever
• No weight loss
• No jaundice
• No recent illness
• No new medications (or specify if present)
4. Past Medical History (PMH)
• Possible history of:
o Atopic dermatitis (eczema)
o Allergies (seasonal, food)
• No chronic systemic illness
5. Medications
• OTC creams or antihistamines (if used)
• No new medications (important for drug reaction)
6. Allergies
• NKDA or specify (e.g., soaps, detergents, foods)
7. Family History
• Atopy (eczema, asthma, allergic rhinitis)
• Skin conditions
8. Social History
• Lives with family
• School-going
• Hygiene habits
• Possible exposure:
o New soaps/detergents
o Pets
o Close contacts with similar symptoms (important for scabies)
, 9. Review of Systems (ROS)
Positive:
• Skin: itching, dryness, rash
Negative:
• Constitutional: no fever, fatigue
• GI: no abdominal pain
• Hepatic: no jaundice
• Endocrine: no heat/cold intolerance
10. Physical Examination
Vitals
• Normal
General
• Alert, mildly uncomfortable due to itching
Skin
Findings depend on diagnosis but may include:
• Dry, scaly skin
• Erythematous patches
• Excoriations
• Possible:
o Flexural involvement → eczema
o Burrows/web spaces → scabies
o Urticarial wheals → allergy
Other Systems
• Normal (important to rule out systemic disease)
Differential Diagnosis
