i-Human Case Study Week 4: 13-Year-Old Female with Itchy
Skin (Pruritus) - Comprehensive SOAP Note and
Management Plan by i-Human Patients Academic Team |
, PATIENT INFORMATION
• Name: [Patient Name]
• Age: 13 years
• Sex: Female
• DOB: [DOB]
• Encounter Date: [Today's Date]
• CC: "I can't stop itching all over my body."
SUBJECTIVE (HISTORY OF PRESENTING ILLNESS)
Onset: Gradual over the past [2-3 weeks].
Location: Initially started on the [antecubital fossae/popliteal fossae] and has since
spread to the [trunk/neck].
Duration: Intermittent, but worse at night.
Character: Described as an intense "crawling" or "burning" itch.
Aggravating Factors: Reports itching worsens after hot showers, sweating during gym
class, and when wearing wool sweaters.
Relieving Factors: Reports mild, temporary relief with over-the-counter [Cortizone-10 /
Benadryl cream].
Severity: Rates pruritus as 8/10 at its worst, impacting her ability to fall asleep.
Associated Symptoms: Denies fever, chills, night sweats, or weight loss. Reports
associated [dry, scaly patches / raised red welts]. Denies joint pain or jaundice.
Skin (Pruritus) - Comprehensive SOAP Note and
Management Plan by i-Human Patients Academic Team |
, PATIENT INFORMATION
• Name: [Patient Name]
• Age: 13 years
• Sex: Female
• DOB: [DOB]
• Encounter Date: [Today's Date]
• CC: "I can't stop itching all over my body."
SUBJECTIVE (HISTORY OF PRESENTING ILLNESS)
Onset: Gradual over the past [2-3 weeks].
Location: Initially started on the [antecubital fossae/popliteal fossae] and has since
spread to the [trunk/neck].
Duration: Intermittent, but worse at night.
Character: Described as an intense "crawling" or "burning" itch.
Aggravating Factors: Reports itching worsens after hot showers, sweating during gym
class, and when wearing wool sweaters.
Relieving Factors: Reports mild, temporary relief with over-the-counter [Cortizone-10 /
Benadryl cream].
Severity: Rates pruritus as 8/10 at its worst, impacting her ability to fall asleep.
Associated Symptoms: Denies fever, chills, night sweats, or weight loss. Reports
associated [dry, scaly patches / raised red welts]. Denies joint pain or jaundice.
