i-Human Case Study Week 4: 13-Year-Old Female with Itchy
Skin (Pruritus) - Comprehensive SOAP Note and
Management Plan by i-Human Patients |
,PATIENT OVERVIEW
SUBJECTIVE (S)
History of Present Illness (HPI)
Emma Rodriguez is a 13-year-old female presenting with generalized pruritus that began
approximately 2–3 weeks ago. The itching initially started on the flexural surfaces of the
arms and behind the knees, with gradual spread to the neck and wrists. The patient
describes the itching as persistent, rated 6/10 in severity, and worse at night—
significantly disrupting sleep.
OLDCARTS Format:
Component Finding
Onset Gradual, approximately 2–3 weeks ago
, Component Finding
Location Flexural areas (antecubital and popliteal fossae), neck, wrists
Duration Persistent, continuous
Character Intense itching with dry, red, scaly patches
Aggravating factors Hot showers, sweating, heat, scented soaps, wool fabrics, stress
Relieving factors Unscented moisturizers (temporary relief), cool compresses
Timing Worse at night; causes sleep disturbance
Severity Moderate (6/10)
Associated Symptoms:
• Dry skin (xerosis)
• Erythematous patches
• Excoriations from scratching
• Mild sleep disturbance
Pertinent Negatives:
• Denies fever, chills, or malaise
• Denies pain, burning sensation, or bleeding
• Denies purulent drainage, vesicles, or pustules
• Denies weight loss, fatigue, or joint pain
• Denies recent travel, insect bites, or sick contacts
• Denies new soaps, detergents, lotions, or medications
Past Medical History (PMH)
Condition Details
Atopic dermatitis (eczema) Diagnosed as infant; intermittent flares; generally well-controlled
Asthma Mild intermittent; no exacerbations in past 2 years
Skin (Pruritus) - Comprehensive SOAP Note and
Management Plan by i-Human Patients |
,PATIENT OVERVIEW
SUBJECTIVE (S)
History of Present Illness (HPI)
Emma Rodriguez is a 13-year-old female presenting with generalized pruritus that began
approximately 2–3 weeks ago. The itching initially started on the flexural surfaces of the
arms and behind the knees, with gradual spread to the neck and wrists. The patient
describes the itching as persistent, rated 6/10 in severity, and worse at night—
significantly disrupting sleep.
OLDCARTS Format:
Component Finding
Onset Gradual, approximately 2–3 weeks ago
, Component Finding
Location Flexural areas (antecubital and popliteal fossae), neck, wrists
Duration Persistent, continuous
Character Intense itching with dry, red, scaly patches
Aggravating factors Hot showers, sweating, heat, scented soaps, wool fabrics, stress
Relieving factors Unscented moisturizers (temporary relief), cool compresses
Timing Worse at night; causes sleep disturbance
Severity Moderate (6/10)
Associated Symptoms:
• Dry skin (xerosis)
• Erythematous patches
• Excoriations from scratching
• Mild sleep disturbance
Pertinent Negatives:
• Denies fever, chills, or malaise
• Denies pain, burning sensation, or bleeding
• Denies purulent drainage, vesicles, or pustules
• Denies weight loss, fatigue, or joint pain
• Denies recent travel, insect bites, or sick contacts
• Denies new soaps, detergents, lotions, or medications
Past Medical History (PMH)
Condition Details
Atopic dermatitis (eczema) Diagnosed as infant; intermittent flares; generally well-controlled
Asthma Mild intermittent; no exacerbations in past 2 years
