I-HUMAN CASE STUDY ALICIA SMILEY – ATOPIC
DERMATITIS ASSESSMENT, DIFFERENTIAL
DIAGNOSIS, AND TREATMENT PLAN
,Part 1: Patient Bio Data & Initial Data Gathering
Category Details
Name Alicia Smiley
Age [Pediatric/Adolescent – Typically 8-12 years old]
Gender Female
Source Patient and mother
Reliability Patient is reliable; mother provides collateral history
,Category Details
Allergies No Known Drug Allergies (NKDA) – confirm
Chief Complaint: “I have a really itchy rash that won’t go
away.” / “My skin is dry and red, and it keeps me up at
night.”
Reason for Encounter: Follow-up or initial visit for
worsening atopic dermatitis (eczema) unresponsive to
over-the-counter treatments.
Part 2: Past Medical History (PMH)
Condition Details
Atopic Dermatitis
Chronic condition since infancy
(Eczema)
Often co-exists with atopic dermatitis; may
Asthma
be mild intermittent
Allergic Rhinitis Common comorbid condition
May have known triggers (peanuts, eggs,
Food Allergies
dairy)
Key Points:
, History of “the itch that rashes” – itching precedes
rash
Flare-ups often triggered by seasonal changes,
stress, or certain foods
Family history of atopy (eczema, asthma, allergies) is
common
Part 3: Medications
Current Medications
Dos Frequen Prescrib Purpo
Medication
e cy er se
Hydrocortisone PR Occasio Sympto
Self
1% OTC cream N nal m relief
Antihistamines
PR Itch
(Diphenhydram PRN Self
N control
ine)
Treatment Gaps
No prescription topical corticosteroids used
No consistent moisturizing routine
No bleach baths or wet wrap therapy attempted
DERMATITIS ASSESSMENT, DIFFERENTIAL
DIAGNOSIS, AND TREATMENT PLAN
,Part 1: Patient Bio Data & Initial Data Gathering
Category Details
Name Alicia Smiley
Age [Pediatric/Adolescent – Typically 8-12 years old]
Gender Female
Source Patient and mother
Reliability Patient is reliable; mother provides collateral history
,Category Details
Allergies No Known Drug Allergies (NKDA) – confirm
Chief Complaint: “I have a really itchy rash that won’t go
away.” / “My skin is dry and red, and it keeps me up at
night.”
Reason for Encounter: Follow-up or initial visit for
worsening atopic dermatitis (eczema) unresponsive to
over-the-counter treatments.
Part 2: Past Medical History (PMH)
Condition Details
Atopic Dermatitis
Chronic condition since infancy
(Eczema)
Often co-exists with atopic dermatitis; may
Asthma
be mild intermittent
Allergic Rhinitis Common comorbid condition
May have known triggers (peanuts, eggs,
Food Allergies
dairy)
Key Points:
, History of “the itch that rashes” – itching precedes
rash
Flare-ups often triggered by seasonal changes,
stress, or certain foods
Family history of atopy (eczema, asthma, allergies) is
common
Part 3: Medications
Current Medications
Dos Frequen Prescrib Purpo
Medication
e cy er se
Hydrocortisone PR Occasio Sympto
Self
1% OTC cream N nal m relief
Antihistamines
PR Itch
(Diphenhydram PRN Self
N control
ine)
Treatment Gaps
No prescription topical corticosteroids used
No consistent moisturizing routine
No bleach baths or wet wrap therapy attempted
