Krista Hampton I-Human Case Study 25 Years Old Female
CC: “Itchy tender rash to bilateral inner thighs and left
inner forearm that began 1-2 days ago”
Patient Information:
Miss K.H., 25-yr-old, Female
S.
CC: ”Itchy tender rash to bilateral inner thighs and left inner forearm that began 1-2 days ago”.
HPI: The patient is a 25 -year- old Caucasian female who presented with complaints of a itchy
tender rash to her bilateral inner thighs and left inner forearm after hiking with her significant
other in the woods and bushwhacking over the weekend. Patient denies any other symptoms.
Location: Bilateral inner thighs, inner left forearm
Onset: 1-2 days ago
Character: Itchy and tender
Associated signs and symptoms: None reported
Timing: reported to have started one to two days ago following a hiking trip in the woods
Exacerbating/ relieving factors: None reported
Severity: No severity reported
Current Medications:
Birth Control
Allergies: Ceclor: Diagnosed as a child and caused rash
PMHx: None
Soc Hx:
Single, Monogamous relationship
Looking for job as teacher
Sexually active - BCP
Fam Hx:
, Maternal grandfather died of CVD at age 81l grandmother (age 88) has prior heart attack, stent
and HTN.
Mother alive and well. Father alive and well, treated for HTN.
Brothers - 35 and 32 both alive and well.
Sister - 21 alive and well
ROS:
GENERAL: Patient is alert and oriented x 4. Negative for weight loss, chills. Appears anxious
due to symptoms but communicative.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose,
Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: Negative for rash, burning or itching. Negative for change in skin pigmentation.
CARDIOVASCULAR: Negative for chest pain, pressure, or discomfort. Negative for dyspnea,
palpitations, or edema.
RESPIRATORY: Negative for dyspnea, cough, or sputum.
GASTROINTESTINAL: Negative for loss of appetite, nausea, vomiting or diarrhea. Negative
for abdominal pain, constipation, or blood in stool.
GENITOURINARY: Negative for difficulty urinating. Negative for burning, frequent urination,
or blood in urine .
NEUROLOGICAL: Negative for headache, dizziness, or syncope. Negative for change in
bowel or bladder control.
MUSCULOSKELETAL: Negative for weakness in bilateral upper and lower extremities.
Negative for muscle, joint pain, or stiffness in bilateral upper and lower extremities. Full range
of motion in upper and lower extremities.
HEMATOLOGIC: Negative for anemia, bleeding, or hematoma.
LYMPHATICS: Negative for inflamed or enlarged nodes.
PSYCHIATRIC: Negative for depression or diagnosed anxiety.
ENDOCRINOLOGIC: Negative for reports of sweating, cold or heat intolerance.
ALLERGIES: Negative for history of asthma, inflammation, or eczema.
O.
CC: “Itchy tender rash to bilateral inner thighs and left
inner forearm that began 1-2 days ago”
Patient Information:
Miss K.H., 25-yr-old, Female
S.
CC: ”Itchy tender rash to bilateral inner thighs and left inner forearm that began 1-2 days ago”.
HPI: The patient is a 25 -year- old Caucasian female who presented with complaints of a itchy
tender rash to her bilateral inner thighs and left inner forearm after hiking with her significant
other in the woods and bushwhacking over the weekend. Patient denies any other symptoms.
Location: Bilateral inner thighs, inner left forearm
Onset: 1-2 days ago
Character: Itchy and tender
Associated signs and symptoms: None reported
Timing: reported to have started one to two days ago following a hiking trip in the woods
Exacerbating/ relieving factors: None reported
Severity: No severity reported
Current Medications:
Birth Control
Allergies: Ceclor: Diagnosed as a child and caused rash
PMHx: None
Soc Hx:
Single, Monogamous relationship
Looking for job as teacher
Sexually active - BCP
Fam Hx:
, Maternal grandfather died of CVD at age 81l grandmother (age 88) has prior heart attack, stent
and HTN.
Mother alive and well. Father alive and well, treated for HTN.
Brothers - 35 and 32 both alive and well.
Sister - 21 alive and well
ROS:
GENERAL: Patient is alert and oriented x 4. Negative for weight loss, chills. Appears anxious
due to symptoms but communicative.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose,
Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: Negative for rash, burning or itching. Negative for change in skin pigmentation.
CARDIOVASCULAR: Negative for chest pain, pressure, or discomfort. Negative for dyspnea,
palpitations, or edema.
RESPIRATORY: Negative for dyspnea, cough, or sputum.
GASTROINTESTINAL: Negative for loss of appetite, nausea, vomiting or diarrhea. Negative
for abdominal pain, constipation, or blood in stool.
GENITOURINARY: Negative for difficulty urinating. Negative for burning, frequent urination,
or blood in urine .
NEUROLOGICAL: Negative for headache, dizziness, or syncope. Negative for change in
bowel or bladder control.
MUSCULOSKELETAL: Negative for weakness in bilateral upper and lower extremities.
Negative for muscle, joint pain, or stiffness in bilateral upper and lower extremities. Full range
of motion in upper and lower extremities.
HEMATOLOGIC: Negative for anemia, bleeding, or hematoma.
LYMPHATICS: Negative for inflamed or enlarged nodes.
PSYCHIATRIC: Negative for depression or diagnosed anxiety.
ENDOCRINOLOGIC: Negative for reports of sweating, cold or heat intolerance.
ALLERGIES: Negative for history of asthma, inflammation, or eczema.
O.
