,
,Patient Information
Name: Not specified (referred to as “Jane Doe” for clarity, per
iHuman convention)
Age: 36 years old
Gender: Female
Height: 5’4” (163 cm, based on average for adult females)
Weight: 130 lbs (59 kg, BMI 22.3 kg/m², normal)
Reason for Encounter: Itchy rash for 5 days
Setting: Outpatient clinic with laboratory capabilities
Class: 6512, Week #4, Walden University
Date and Time: July 17, 2025, 11:24 AM
History of Present Illness (HPI)
Jane Doe, a 36-year-old Caucasian female, presents to the outpatient
clinic with a 5-day history of an itchy rash described as red, papular,
and intensely pruritic, primarily affecting the flexural surfaces of both
forearms, antecubital fossae, and anterior neck. She rates the itchiness
as 6/10, with exacerbation at night leading to sleep disruption and
occasional burning sensation when scratching. The rash began 1 day
, after using a new laundry detergent, strongly suggesting an allergic
trigger. Jane reports no fever, chills, purulent discharge, swollen lymph
nodes, joint pain, or systemic symptoms (e.g., fatigue, weight loss),
reducing suspicion for infectious or systemic etiologies. She denies
recent travel, insect bites, new medications, new soaps, cosmetics, or
occupational exposures to irritants beyond the detergent. Over-the-
counter hydrocortisone 1% cream (applied twice daily for 3 days)
provided minimal relief, and oral diphenhydramine 25 mg at night (2–3
doses) reduced itching slightly but caused significant drowsiness,
limiting its use.Jane has a history of seasonal allergic rhinitis (spring,
controlled with cetirizine 10 mg PRN, not currently needed) and mild
eczema in childhood (resolved by age 12, no recent flares). She denies
asthma, food allergies, psoriasis, or autoimmune disorders. As an office
manager, Jane has no occupational exposure to chemicals or irritants,
and her work involves minimal physical stress. She lives with her
husband and two children (ages 8 and 10) in a suburban home, follows
a balanced diet (fruits, vegetables, lean proteins, no recent changes),
and engages in moderate exercise (30 minutes walking, 3–4
times/week). Jane denies smoking, uses alcohol socially (1–2 glasses of
wine/week), and reports no illicit drug use. She notes moderate stress
from balancing work and parenting responsibilities, which may
exacerbate itching. Her last menstrual period was 2 weeks ago, and she
,Patient Information
Name: Not specified (referred to as “Jane Doe” for clarity, per
iHuman convention)
Age: 36 years old
Gender: Female
Height: 5’4” (163 cm, based on average for adult females)
Weight: 130 lbs (59 kg, BMI 22.3 kg/m², normal)
Reason for Encounter: Itchy rash for 5 days
Setting: Outpatient clinic with laboratory capabilities
Class: 6512, Week #4, Walden University
Date and Time: July 17, 2025, 11:24 AM
History of Present Illness (HPI)
Jane Doe, a 36-year-old Caucasian female, presents to the outpatient
clinic with a 5-day history of an itchy rash described as red, papular,
and intensely pruritic, primarily affecting the flexural surfaces of both
forearms, antecubital fossae, and anterior neck. She rates the itchiness
as 6/10, with exacerbation at night leading to sleep disruption and
occasional burning sensation when scratching. The rash began 1 day
, after using a new laundry detergent, strongly suggesting an allergic
trigger. Jane reports no fever, chills, purulent discharge, swollen lymph
nodes, joint pain, or systemic symptoms (e.g., fatigue, weight loss),
reducing suspicion for infectious or systemic etiologies. She denies
recent travel, insect bites, new medications, new soaps, cosmetics, or
occupational exposures to irritants beyond the detergent. Over-the-
counter hydrocortisone 1% cream (applied twice daily for 3 days)
provided minimal relief, and oral diphenhydramine 25 mg at night (2–3
doses) reduced itching slightly but caused significant drowsiness,
limiting its use.Jane has a history of seasonal allergic rhinitis (spring,
controlled with cetirizine 10 mg PRN, not currently needed) and mild
eczema in childhood (resolved by age 12, no recent flares). She denies
asthma, food allergies, psoriasis, or autoimmune disorders. As an office
manager, Jane has no occupational exposure to chemicals or irritants,
and her work involves minimal physical stress. She lives with her
husband and two children (ages 8 and 10) in a suburban home, follows
a balanced diet (fruits, vegetables, lean proteins, no recent changes),
and engages in moderate exercise (30 minutes walking, 3–4
times/week). Jane denies smoking, uses alcohol socially (1–2 glasses of
wine/week), and reports no illicit drug use. She notes moderate stress
from balancing work and parenting responsibilities, which may
exacerbate itching. Her last menstrual period was 2 weeks ago, and she
