,Patient Information
Name: Emily Chen (per iHuman case documentation)
Age: 25 years
Gender: Female
Height: 5’4” (162.6 cm, approximately 50th percentile for age)
Weight: 130 lb (59 kg, BMI 22.3 kg/m², normal range, 18.5–24.9
kg/m²)
Reason for Encounter: New-onset rash for 1 week, presenting to a
primary care clinic in 2024 for evaluation.
History of Present Illness
Emily Chen, a 25-year-old female graduate student, presents to the
primary care clinic with a chief complaint of a new, intensely itchy rash
that began 7 days ago. She describes the rash as red, raised, and
pruritic, initially appearing on her bilateral forearms and subsequently
spreading to her thighs, abdomen, lower back, and upper arms. The
lesions are described as “bumpy” and vary in size from small dots to
larger patches (2–5 cm). She rates the itching as 7/10 in severity, with
exacerbations at night that disrupt her sleep, leading to visible scratch
marks (excoriations) on her arms and legs. The patient denies pain,
burning, warmth, or discharge (e.g., oozing, crusting) from the lesions.
,She reports mild swelling around the larger rash patches but no facial
swelling, lip swelling, throat tightness, difficulty breathing, or mucosal
involvement (e.g., mouth sores). She also denies fever, chills, night
sweats, or systemic symptoms such as weight loss or fatigue beyond
what she attributes to sleep disruption from itching. Emily notes that
she started amoxicillin 500 mg three times daily 2 weeks ago (14 days
prior to the visit) for a sinus infection characterized by nasal congestion,
facial pain, and purulent discharge. The sinus infection resolved, and
she completed the 10-day amoxicillin course 4 days ago. The rash
began 3 days before completing the antibiotic, suggesting a possible
delayed hypersensitivity reaction. She denies starting other new
medications, supplements, or herbal remedies. She reports no recent
changes in soaps, detergents, lotions, cosmetics, or clothing (e.g., new
fabrics). She denies exposure to potential contact allergens such as
poison ivy, nickel, or fragrances, and has not introduced new foods or
experienced environmental changes (e.g., travel, pet exposure). She
lives alone in an apartment and confirms no recent insect bites, tick
exposure, or contact with individuals with similar rashes. Associated
symptoms include mild fatigue, which she attributes to sleeping only 5–
6 hours per night due to itching, compared to her usual 7–8 hours. She
also reports occasional tension-type headaches, a chronic issue
occurring 1–2 times per week, managed with ibuprofen 400 mg as
, needed. She denies new or worsening headaches, joint pain, muscle
aches, nausea, vomiting, diarrhea, abdominal pain, or urinary
symptoms (e.g., dysuria, hematuria). Emily is concerned about the
rash’s cosmetic appearance, as it is visible on her arms and legs, and its
impact on her sleep and ability to focus on her graduate studies. She
has tried applying over-the-counter hydrocortisone 1% cream to the
rash with minimal relief and has taken cetirizine 10 mg intermittently
for itching, which provides partial improvement. Medical History
Past Medical History:
Seasonal Allergic Rhinitis: Diagnosed in adolescence,
triggered by pollen (spring and fall), managed with over-the-
counter cetirizine 10 mg as needed. Last used 1 month ago
during allergy season, with good symptom control.
Acute Sinusitis: Diagnosed 2 weeks ago by her primary care
provider, treated with amoxicillin 500 mg three times daily
for 10 days, completed 4 days ago. Symptoms (nasal
congestion, facial pain, purulent discharge) fully resolved.
No history of eczema, psoriasis, asthma, autoimmune
diseases, or chronic skin conditions.
No history of hospitalizations, surgeries, or other chronic
illnesses (e.g., diabetes, thyroid disease).
Name: Emily Chen (per iHuman case documentation)
Age: 25 years
Gender: Female
Height: 5’4” (162.6 cm, approximately 50th percentile for age)
Weight: 130 lb (59 kg, BMI 22.3 kg/m², normal range, 18.5–24.9
kg/m²)
Reason for Encounter: New-onset rash for 1 week, presenting to a
primary care clinic in 2024 for evaluation.
History of Present Illness
Emily Chen, a 25-year-old female graduate student, presents to the
primary care clinic with a chief complaint of a new, intensely itchy rash
that began 7 days ago. She describes the rash as red, raised, and
pruritic, initially appearing on her bilateral forearms and subsequently
spreading to her thighs, abdomen, lower back, and upper arms. The
lesions are described as “bumpy” and vary in size from small dots to
larger patches (2–5 cm). She rates the itching as 7/10 in severity, with
exacerbations at night that disrupt her sleep, leading to visible scratch
marks (excoriations) on her arms and legs. The patient denies pain,
burning, warmth, or discharge (e.g., oozing, crusting) from the lesions.
,She reports mild swelling around the larger rash patches but no facial
swelling, lip swelling, throat tightness, difficulty breathing, or mucosal
involvement (e.g., mouth sores). She also denies fever, chills, night
sweats, or systemic symptoms such as weight loss or fatigue beyond
what she attributes to sleep disruption from itching. Emily notes that
she started amoxicillin 500 mg three times daily 2 weeks ago (14 days
prior to the visit) for a sinus infection characterized by nasal congestion,
facial pain, and purulent discharge. The sinus infection resolved, and
she completed the 10-day amoxicillin course 4 days ago. The rash
began 3 days before completing the antibiotic, suggesting a possible
delayed hypersensitivity reaction. She denies starting other new
medications, supplements, or herbal remedies. She reports no recent
changes in soaps, detergents, lotions, cosmetics, or clothing (e.g., new
fabrics). She denies exposure to potential contact allergens such as
poison ivy, nickel, or fragrances, and has not introduced new foods or
experienced environmental changes (e.g., travel, pet exposure). She
lives alone in an apartment and confirms no recent insect bites, tick
exposure, or contact with individuals with similar rashes. Associated
symptoms include mild fatigue, which she attributes to sleeping only 5–
6 hours per night due to itching, compared to her usual 7–8 hours. She
also reports occasional tension-type headaches, a chronic issue
occurring 1–2 times per week, managed with ibuprofen 400 mg as
, needed. She denies new or worsening headaches, joint pain, muscle
aches, nausea, vomiting, diarrhea, abdominal pain, or urinary
symptoms (e.g., dysuria, hematuria). Emily is concerned about the
rash’s cosmetic appearance, as it is visible on her arms and legs, and its
impact on her sleep and ability to focus on her graduate studies. She
has tried applying over-the-counter hydrocortisone 1% cream to the
rash with minimal relief and has taken cetirizine 10 mg intermittently
for itching, which provides partial improvement. Medical History
Past Medical History:
Seasonal Allergic Rhinitis: Diagnosed in adolescence,
triggered by pollen (spring and fall), managed with over-the-
counter cetirizine 10 mg as needed. Last used 1 month ago
during allergy season, with good symptom control.
Acute Sinusitis: Diagnosed 2 weeks ago by her primary care
provider, treated with amoxicillin 500 mg three times daily
for 10 days, completed 4 days ago. Symptoms (nasal
congestion, facial pain, purulent discharge) fully resolved.
No history of eczema, psoriasis, asthma, autoimmune
diseases, or chronic skin conditions.
No history of hospitalizations, surgeries, or other chronic
illnesses (e.g., diabetes, thyroid disease).
