Week 4 Case Study, – 13-Year-Old Female with
Itchy Skin
, • Patient: 13-year-old female
• Height: 5 ft 2 in (157 cm)
• Weight: 114 lb (51.7 kg)
• Reason for encounter: Itchy skin (itchy rash)
• Setting: Outpatient clinic with laboratory capabilities
Comprehensive History of Present Illness
(HPI)
Patient: 13-year-old female
Chief Complaint: "My skin has been itching."
History of Present Illness
The patient is a 13-year-old female who presents with complaints of an intensely pruritic rash
that developed approximately 7–14 days ago. The itching initially began on the bilateral
forearms before gradually spreading to the trunk and lower extremities. The patient describes the
pruritus as persistent throughout the day but significantly worse during the evening and
nighttime, resulting in sleep disturbance.
The rash began as small red bumps and has progressively enlarged with continued scratching.
She reports that scratching temporarily relieves the itching but subsequently worsens the
irritation. There is no associated pain, burning, or numbness.
The patient denies fever, chills, fatigue, recent upper respiratory illness, sore throat, abdominal
pain, nausea, vomiting, diarrhea, weight loss, joint pain, oral ulcers, or respiratory symptoms.
She denies recent travel, camping, hiking, swimming in lakes, insect bites, or animal exposure.
She reports no recent use of new prescription medications but may have recently changed soaps,
detergents, lotions, perfumes, or cosmetics. There is no history of food allergies or recent
ingestion of unusual foods.
The patient attends school and participates in sports. She denies classmates with similar
symptoms unless the history suggests contagious disease.
OPQRST/OLDCARTS Assessment
, Onset
• Approximately 1–2 weeks ago
• Gradual progression
Provoking Factors
• Heat
• Sweating
• Wool clothing
• Hot showers
• Scratching
Relieving Factors
• Cool compresses
• Moisturizers
• Temporary relief with antihistamines
Quality
• Intense itching
• Dry irritated skin
Region
• Arms
• Legs
• Trunk
• Neck
• Flexural surfaces (if eczema)
Radiation
• None
Severity
• Itching rated 8/10
Timing
• Constant
• Worse at night