Week 2 i-Human Case Study | 36-Year-Old
Female With Itchy Rash | Outpatient Clinic |
Complete Assessment, Diagnosis &
Management
,1) Summary cover
Patient: Female, 36 years old
CC: "I have an itchy rash" — started 5 days ago, worsening.
Setting: Outpatient primary care / urgent care clinic (Week 2 i-Human case)
Goal: Demonstrate full clinical reasoning from triage → diagnosis → treatment;
teach why each step is done.
Why this matters: Skin complaints are common in outpatient clinics.
Differentiating allergic, infectious, inflammatory, and systemic etiologies is
important, as management (topical steroid, antimicrobial, referral) varies
significantly.
2) Triage & initial assessment: what to do and why
Triage note: Patient ambulatory, comfortable at rest, no respiratory distress,
denies fever.
Vitals: T 37.0°C, HR 78, BP 118/76, RR 14, SpO₂ 99% RA.
Immediate priorities & explanation:
Rapid assessment for systemic involvement to rule out fever, hypotension, and
respiratory compromise that would upgrade acuity.
, Confirm the history timeline and whether the rash is rapidly spreading or
associated with breathing/swelling - possible anaphylaxis. Because none are
present, outpatient evaluation is appropriate.
3) Focused History of Present Illness (HPI) — what to ask and why
Obtain a concise yet focused HPI; each component directs the DDx and workup.
Onset: Rash appeared 5 days ago, began on the forearms then spread to the trunk
and thighs.
Why: The time of onset and progression distinguish a contact dermatitis, which is
localized, from a viral exanthem or drug eruption, which is much more
generalized.
Course: Initially small red spots → coalesced into patches; itching severe 8/10,
worse at night.
Why: Severe pruritus suggests allergic/urticarial/lichenified dermatoses rather
than painless petechial lesions.
Associated symptoms include no fever, no sore throat, no joint pains, no shortness
of breath, no blistering, and no mucosal lesions.
Female With Itchy Rash | Outpatient Clinic |
Complete Assessment, Diagnosis &
Management
,1) Summary cover
Patient: Female, 36 years old
CC: "I have an itchy rash" — started 5 days ago, worsening.
Setting: Outpatient primary care / urgent care clinic (Week 2 i-Human case)
Goal: Demonstrate full clinical reasoning from triage → diagnosis → treatment;
teach why each step is done.
Why this matters: Skin complaints are common in outpatient clinics.
Differentiating allergic, infectious, inflammatory, and systemic etiologies is
important, as management (topical steroid, antimicrobial, referral) varies
significantly.
2) Triage & initial assessment: what to do and why
Triage note: Patient ambulatory, comfortable at rest, no respiratory distress,
denies fever.
Vitals: T 37.0°C, HR 78, BP 118/76, RR 14, SpO₂ 99% RA.
Immediate priorities & explanation:
Rapid assessment for systemic involvement to rule out fever, hypotension, and
respiratory compromise that would upgrade acuity.
, Confirm the history timeline and whether the rash is rapidly spreading or
associated with breathing/swelling - possible anaphylaxis. Because none are
present, outpatient evaluation is appropriate.
3) Focused History of Present Illness (HPI) — what to ask and why
Obtain a concise yet focused HPI; each component directs the DDx and workup.
Onset: Rash appeared 5 days ago, began on the forearms then spread to the trunk
and thighs.
Why: The time of onset and progression distinguish a contact dermatitis, which is
localized, from a viral exanthem or drug eruption, which is much more
generalized.
Course: Initially small red spots → coalesced into patches; itching severe 8/10,
worse at night.
Why: Severe pruritus suggests allergic/urticarial/lichenified dermatoses rather
than painless petechial lesions.
Associated symptoms include no fever, no sore throat, no joint pains, no shortness
of breath, no blistering, and no mucosal lesions.
