Comprehensive i-Human Case Study Week 4 – 25-Year-Old
Female With New-Onset Rash | NURS 6512 Advanced Health
Assessment | Full Clinical Evaluation, History & Physical
Examination, Differential Diagnosis & Comprehensive
Assessment and Plan | 2026 U
,PART I: PATIENT OVERVIEW & CHIEF COMPLAINT
Field Information
Patient Name Victoria Lewis
Age 25 years
Sex Female
Height 165 cm (5'5")
Weight 54.5 kg (120 lb)
BMI 20.0 kg/m² (Normal)
Occupation College student
Setting Primary Care Outpatient Clinic
Encounter Type Acute visit – new rash
Source of History Patient, reliable historian
Language English
Chief Complaint (CC)
"I have a new rash that started a few days ago. It's really itchy and it's spreading."
PART II: COMPREHENSIVE HEALTH HISTORY
A. History of Present Illness (HPI) – With Patient Dialogue
, Nurse Practitioner (NP): "Good morning, Victoria. I understand you're here because of a rash.
Can you tell me when you first noticed it?"
Victoria: "It started about three days ago. I woke up and noticed some red, itchy spots on my
inner thighs. I thought maybe it was just irritation from my jeans, but then it started spreading
to my arms and neck. Now it's on my chest and torso too."
NP: "Can you describe what the rash looks like?"
Victoria: "It's red and bumpy. Some spots are small and raised, and some of them have kind of
merged together into bigger red patches. It's really itchy—like a 6 out of 10. It's worse at night
when I'm trying to sleep."
NP: "Is it painful at all?"
Victoria: "Not really painful, but it burns a little when I scratch it. I've been trying not to scratch,
but it's hard."
NP: "Have you noticed any other symptoms? Fever, chills, sore throat, joint pain?"
Victoria: "I've been a little more tired than usual, but no fever. I had a sore throat about a week
ago, but that went away. My joints feel a little achy, but nothing major."
NP: "Have you started any new medications recently?"
Victoria: "Well, I was prescribed amoxicillin for a sore throat about five days ago. I've been
taking it since then. Could that be causing this?"
NP: "That's very helpful information. Have you ever taken amoxicillin before?"
Victoria: "Yes, I've taken it before and never had a problem. That's why I'm confused."
NP: "Have you used any new soaps, lotions, laundry detergents, or cosmetics recently?"
Victoria: "I did switch to a new laundry detergent about a week ago. And I went hiking last
weekend—I might have come into contact with some plants, but I didn't notice any bug bites."
NP: "Any recent travel, sick contacts, or changes in your sexual history?"
Victoria: "No travel. My roommate had a cold a couple of weeks ago, but I didn't really get sick.
No changes in my sexual history."
NP: "Does anyone in your family have skin conditions or autoimmune diseases?"
Victoria: "My mom has eczema and seasonal allergies. My dad has high blood pressure. No one
has anything serious like lupus or anything."
Female With New-Onset Rash | NURS 6512 Advanced Health
Assessment | Full Clinical Evaluation, History & Physical
Examination, Differential Diagnosis & Comprehensive
Assessment and Plan | 2026 U
,PART I: PATIENT OVERVIEW & CHIEF COMPLAINT
Field Information
Patient Name Victoria Lewis
Age 25 years
Sex Female
Height 165 cm (5'5")
Weight 54.5 kg (120 lb)
BMI 20.0 kg/m² (Normal)
Occupation College student
Setting Primary Care Outpatient Clinic
Encounter Type Acute visit – new rash
Source of History Patient, reliable historian
Language English
Chief Complaint (CC)
"I have a new rash that started a few days ago. It's really itchy and it's spreading."
PART II: COMPREHENSIVE HEALTH HISTORY
A. History of Present Illness (HPI) – With Patient Dialogue
, Nurse Practitioner (NP): "Good morning, Victoria. I understand you're here because of a rash.
Can you tell me when you first noticed it?"
Victoria: "It started about three days ago. I woke up and noticed some red, itchy spots on my
inner thighs. I thought maybe it was just irritation from my jeans, but then it started spreading
to my arms and neck. Now it's on my chest and torso too."
NP: "Can you describe what the rash looks like?"
Victoria: "It's red and bumpy. Some spots are small and raised, and some of them have kind of
merged together into bigger red patches. It's really itchy—like a 6 out of 10. It's worse at night
when I'm trying to sleep."
NP: "Is it painful at all?"
Victoria: "Not really painful, but it burns a little when I scratch it. I've been trying not to scratch,
but it's hard."
NP: "Have you noticed any other symptoms? Fever, chills, sore throat, joint pain?"
Victoria: "I've been a little more tired than usual, but no fever. I had a sore throat about a week
ago, but that went away. My joints feel a little achy, but nothing major."
NP: "Have you started any new medications recently?"
Victoria: "Well, I was prescribed amoxicillin for a sore throat about five days ago. I've been
taking it since then. Could that be causing this?"
NP: "That's very helpful information. Have you ever taken amoxicillin before?"
Victoria: "Yes, I've taken it before and never had a problem. That's why I'm confused."
NP: "Have you used any new soaps, lotions, laundry detergents, or cosmetics recently?"
Victoria: "I did switch to a new laundry detergent about a week ago. And I went hiking last
weekend—I might have come into contact with some plants, but I didn't notice any bug bites."
NP: "Any recent travel, sick contacts, or changes in your sexual history?"
Victoria: "No travel. My roommate had a cold a couple of weeks ago, but I didn't really get sick.
No changes in my sexual history."
NP: "Does anyone in your family have skin conditions or autoimmune diseases?"
Victoria: "My mom has eczema and seasonal allergies. My dad has high blood pressure. No one
has anything serious like lupus or anything."
