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 |
2025/2026 Edition - Ace Your Exams on First
Attempt
,## I. PATIENT INFORMATION
| Field | Data |
, | :--- | :--- |
| **Age** | 13 years |
| **Sex** | Female |
| **Chief Complaint** | "My skin has been really itchy for the last
few weeks" |
| **Setting** | Outpatient pediatric clinic |
| **Source of History** | Patient and mother (both reliable) |
---
## II. SUBJECTIVE (S) – History of Present Illness
### History of Present Illness (HPI)
The patient is a 13-year-old female who presents with her mother for
a chief complaint of generalized pruritus (itching) that began
approximately 10 days to 3 weeks ago. The itching initially started on
the flexural surfaces of the elbows and knees and has since spread to
involve the wrists, posterior neck, lower abdomen, and ankles. She
describes the sensation as persistent, moderate to severe (rated 6-
8/10 during exacerbations), and significantly worse at night, often
interfering with sleep .
The patient reports dry, rough skin over her arms, legs, and trunk,
with increased scratching, particularly at night. She notes occasional
mild redness in affected areas. Initially, there were no visible pus,
blisters, or open wounds, though scratching has led to some bleeding
Female with Itchy Skin (Pruritus) -
Comprehensive SOAP Note and Management
Plan by i-Human Patients Academic Team |
2025/2026 Edition - Ace Your Exams on First
Attempt
,## I. PATIENT INFORMATION
| Field | Data |
, | :--- | :--- |
| **Age** | 13 years |
| **Sex** | Female |
| **Chief Complaint** | "My skin has been really itchy for the last
few weeks" |
| **Setting** | Outpatient pediatric clinic |
| **Source of History** | Patient and mother (both reliable) |
---
## II. SUBJECTIVE (S) – History of Present Illness
### History of Present Illness (HPI)
The patient is a 13-year-old female who presents with her mother for
a chief complaint of generalized pruritus (itching) that began
approximately 10 days to 3 weeks ago. The itching initially started on
the flexural surfaces of the elbows and knees and has since spread to
involve the wrists, posterior neck, lower abdomen, and ankles. She
describes the sensation as persistent, moderate to severe (rated 6-
8/10 during exacerbations), and significantly worse at night, often
interfering with sleep .
The patient reports dry, rough skin over her arms, legs, and trunk,
with increased scratching, particularly at night. She notes occasional
mild redness in affected areas. Initially, there were no visible pus,
blisters, or open wounds, though scratching has led to some bleeding
