FOR ENCOUNTER ITCHY RASH
,PATIENT INFORMATION
AGE: 36 Y O FEMALE
HEIGHT: 50 (152 cm)
WEIGHT: 55kg
Reason for encounter: Itchy rash
Location: Outpatient clinic with laboratory capabilities
1. EXTENSIVE PATIENT INFORMATION
The patient is a 36-year-old female presenting to the outpatient primary care clinic, which is fully
equipped with laboratory capabilities and access to dermatologic diagnostic tools. She is 5’0”
(152 cm) tall and weighs 55 kg, giving her a BMI of approximately 23.8, categorized as normal
weight. She is employed as a retail worker in a beauty supply store and frequently handles
various cosmetic products, topical fragrances, latex gloves, and hair-treatment chemicals. She
lives in an urban apartment with her partner and two children, and reports no known chronic
medical conditions aside from seasonal allergies for which she uses over-the-counter
antihistamines intermittently. She denies tobacco use and recreational drug use but drinks wine
socially on weekends. Her immunizations are current. She has no known medication allergies but
, reports mild sensitivity to nickel jewelry, which causes transient itching and redness. Recently,
she switched to a new brand of laundry detergent and began testing new cosmetic products at
work. She has no history of autoimmune disease, eczema, psoriasis, or chronic dermatologic
disorders. Family history is notable only for maternal asthma and paternal hypertension. Her
overall lifestyle is active, and she engages in regular workouts at a local gym. The patient’s
socioeconomic status is moderate, and she denies financial barriers to accessing healthcare or
medications. She expresses high concern about the appearance of her skin due to her profession,
which requires face-to-face interaction with customers. Her primary goal for today’s visit is
relief of an intensely itchy rash that has progressively worsened despite over-the-counter
remedies.