Kaylee Hales – I-Human
Patient and Encounter
● Patient: Kaylee Hales
● Age: 25-year-old female
● Height: 5'5"
● Weight: 120 lb
● BMI: 20
● Reason for encounter: New rash
● Setting: Outpatient clinic with laboratory, ECG, and X-ray capabilities
● PMH: No significant medical history
● Current medications: Oral contraceptive
● Allergies: Cefaclor — causes rash
● Immunizations: Up to date; received influenza and HPV vaccines
● Current complaint: Intensely pruritic erythematous rash for approximately 2 days
● Initial location: Inner thighs
● Spread: Left inner forearm
● Recent exposures: Hiking/bushwhacking through brush, new suntan lotion, and hot-tub exposure
● Associated symptoms: Severe itching and tenderness from scratching; denies systemic
symptoms
History
General
● How can I help you today?
● When did the rash begin?
● Where did you first notice it?
● Has the rash spread?
● Is the rash getting better or worse?
● Is the rash painful or itchy?
● How severe is the itching?
● Have you tried anything to treat it?
● Have you had a similar rash before?
Rash Characteristics
● What does the rash look like?
● Are there bumps, blisters, or areas of redness?
● Are the lesions filled with fluid?
● Are they painful or primarily itchy?
● Are the lesions clustered together or separated?
● Does anything make the itching worse?
, ● Does anything relieve the itching?
● Have you noticed drainage or crusting?
● Have you noticed warmth or swelling?
Exposure History
● Have you recently been hiking or outdoors?
● Did you walk through brush, woods, or plants?
● Were your arms or legs exposed?
● Did you use any new lotions, creams, soaps, or detergents?
● Did you use sunscreen or suntan lotion?
● Was the product different from your usual product?
● Have you recently used a hot tub or swimming pool?
● Have you been bitten by insects?
● Have you had contact with anyone with a similar rash?
Associated Symptoms
● Any fever or chills?
● Any fatigue or malaise?
● Any headache?
● Any difficulty breathing?
● Any facial or lip swelling?
● Any nausea or vomiting?
● Any joint pain?
● Any swelling of the lymph nodes?
Food/Allergy History
● Have you eaten any new foods recently?
● Did you eat anything unusual while traveling?
● Have you eaten scallops or shellfish before?
● Any history of food allergies?
● Any history of eczema or other skin conditions?
● Any previous allergic reactions?
Past History
● Any chronic medical conditions?
● Previous skin disorders?
● Previous allergic reactions?
● Previous hospitalizations?
● Previous surgeries?
● Recent illnesses?
● Recent antibiotic use?
Patient and Encounter
● Patient: Kaylee Hales
● Age: 25-year-old female
● Height: 5'5"
● Weight: 120 lb
● BMI: 20
● Reason for encounter: New rash
● Setting: Outpatient clinic with laboratory, ECG, and X-ray capabilities
● PMH: No significant medical history
● Current medications: Oral contraceptive
● Allergies: Cefaclor — causes rash
● Immunizations: Up to date; received influenza and HPV vaccines
● Current complaint: Intensely pruritic erythematous rash for approximately 2 days
● Initial location: Inner thighs
● Spread: Left inner forearm
● Recent exposures: Hiking/bushwhacking through brush, new suntan lotion, and hot-tub exposure
● Associated symptoms: Severe itching and tenderness from scratching; denies systemic
symptoms
History
General
● How can I help you today?
● When did the rash begin?
● Where did you first notice it?
● Has the rash spread?
● Is the rash getting better or worse?
● Is the rash painful or itchy?
● How severe is the itching?
● Have you tried anything to treat it?
● Have you had a similar rash before?
Rash Characteristics
● What does the rash look like?
● Are there bumps, blisters, or areas of redness?
● Are the lesions filled with fluid?
● Are they painful or primarily itchy?
● Are the lesions clustered together or separated?
● Does anything make the itching worse?
, ● Does anything relieve the itching?
● Have you noticed drainage or crusting?
● Have you noticed warmth or swelling?
Exposure History
● Have you recently been hiking or outdoors?
● Did you walk through brush, woods, or plants?
● Were your arms or legs exposed?
● Did you use any new lotions, creams, soaps, or detergents?
● Did you use sunscreen or suntan lotion?
● Was the product different from your usual product?
● Have you recently used a hot tub or swimming pool?
● Have you been bitten by insects?
● Have you had contact with anyone with a similar rash?
Associated Symptoms
● Any fever or chills?
● Any fatigue or malaise?
● Any headache?
● Any difficulty breathing?
● Any facial or lip swelling?
● Any nausea or vomiting?
● Any joint pain?
● Any swelling of the lymph nodes?
Food/Allergy History
● Have you eaten any new foods recently?
● Did you eat anything unusual while traveling?
● Have you eaten scallops or shellfish before?
● Any history of food allergies?
● Any history of eczema or other skin conditions?
● Any previous allergic reactions?
Past History
● Any chronic medical conditions?
● Previous skin disorders?
● Previous allergic reactions?
● Previous hospitalizations?
● Previous surgeries?
● Recent illnesses?
● Recent antibiotic use?
