Comprehensive i-Human Clinical Case Report (2026):
Holistic Evaluation of a New Rash in a Young Adult
Female, Featuring Structured History Taking, Focused
Physical Examination, Differential Diagnosis Analysis,
EvidenceBased Treatment, Patient Education, R
Patient Introduction
,A 24-year-old female presents to an outpatient primary care clinic with a chief complaint of a newly
developed skin rash. She appears well, in no acute distress, and is seeking evaluation due to worsening
symptoms and cosmetic concerns. The clinic has laboratory and limited diagnostic capabilities.
Chief Complaint (CC)
“I developed a rash on my arms and trunk that is itchy and spreading.”
History of Present Illness (HPI)
The patient reports the onset of a rash approximately 5 days prior to presentation. The rash initially
appeared on the bilateral forearms and has since spread to the upper chest and abdomen. She describes
the rash as erythematous, pruritic, and slightly raised. Pruritus is moderate and worse at night. She
denies pain, vesicles, drainage, bleeding, or ulceration.
She reports recent use of a new scented body lotion started one week ago. She also notes increased
outdoor activity over the past two weekends. She denies fever, chills, fatigue, sore throat, cough,
dyspnea, joint pain, or gastrointestinal symptoms. No similar symptoms in household contacts.
She has not attempted prescription treatment but has used over-the-counter calamine lotion with
minimal relief.
Past Medical History (PMH)
• No chronic medical conditions
• No history of eczema, psoriasis, or autoimmune disease
Past Surgical History (PSH)
• Denies prior surgeries
Medications
• Multivitamin daily
• Occasional ibuprofen for headaches
Allergies
• No known drug allergies (NKDA)
, Family History
• Mother: Seasonal allergic rhinitis
• Father: Hypertension
• No family history of autoimmune or dermatologic disease
Social History
• Lives alone
• Works as a university student
• Denies tobacco or illicit drug use
• Occasional alcohol consumption
• No recent travel
Review of Systems (ROS)
General: Denies fever, weight loss, night sweats Skin: Positive for pruritic rash; denies lesions, ulcers, or
pigment changes HEENT: Denies sore throat, oral lesions Respiratory: Denies cough or shortness of
breath Cardiovascular: Denies chest pain or palpitations Gastrointestinal: Denies nausea, vomiting,
diarrhea Musculoskeletal: Denies joint pain or swelling Neurologic: Denies headaches or weakness
Physical Examination
Vital Signs:
• BP: 112/72 mmHg
• HR: 76 bpm
• RR: 16/min
• Temp: 98.4°F (36.9°C)
• SpO₂: 99% on room air
General: Alert, oriented, well-appearing female
Skin:
• Erythematous, maculopapular rash on bilateral forearms, upper chest, and abdomen
• Poorly demarcated borders
• No vesicles, pustules, scaling, or crusting
Holistic Evaluation of a New Rash in a Young Adult
Female, Featuring Structured History Taking, Focused
Physical Examination, Differential Diagnosis Analysis,
EvidenceBased Treatment, Patient Education, R
Patient Introduction
,A 24-year-old female presents to an outpatient primary care clinic with a chief complaint of a newly
developed skin rash. She appears well, in no acute distress, and is seeking evaluation due to worsening
symptoms and cosmetic concerns. The clinic has laboratory and limited diagnostic capabilities.
Chief Complaint (CC)
“I developed a rash on my arms and trunk that is itchy and spreading.”
History of Present Illness (HPI)
The patient reports the onset of a rash approximately 5 days prior to presentation. The rash initially
appeared on the bilateral forearms and has since spread to the upper chest and abdomen. She describes
the rash as erythematous, pruritic, and slightly raised. Pruritus is moderate and worse at night. She
denies pain, vesicles, drainage, bleeding, or ulceration.
She reports recent use of a new scented body lotion started one week ago. She also notes increased
outdoor activity over the past two weekends. She denies fever, chills, fatigue, sore throat, cough,
dyspnea, joint pain, or gastrointestinal symptoms. No similar symptoms in household contacts.
She has not attempted prescription treatment but has used over-the-counter calamine lotion with
minimal relief.
Past Medical History (PMH)
• No chronic medical conditions
• No history of eczema, psoriasis, or autoimmune disease
Past Surgical History (PSH)
• Denies prior surgeries
Medications
• Multivitamin daily
• Occasional ibuprofen for headaches
Allergies
• No known drug allergies (NKDA)
, Family History
• Mother: Seasonal allergic rhinitis
• Father: Hypertension
• No family history of autoimmune or dermatologic disease
Social History
• Lives alone
• Works as a university student
• Denies tobacco or illicit drug use
• Occasional alcohol consumption
• No recent travel
Review of Systems (ROS)
General: Denies fever, weight loss, night sweats Skin: Positive for pruritic rash; denies lesions, ulcers, or
pigment changes HEENT: Denies sore throat, oral lesions Respiratory: Denies cough or shortness of
breath Cardiovascular: Denies chest pain or palpitations Gastrointestinal: Denies nausea, vomiting,
diarrhea Musculoskeletal: Denies joint pain or swelling Neurologic: Denies headaches or weakness
Physical Examination
Vital Signs:
• BP: 112/72 mmHg
• HR: 76 bpm
• RR: 16/min
• Temp: 98.4°F (36.9°C)
• SpO₂: 99% on room air
General: Alert, oriented, well-appearing female
Skin:
• Erythematous, maculopapular rash on bilateral forearms, upper chest, and abdomen
• Poorly demarcated borders
• No vesicles, pustules, scaling, or crusting
