IHuman Case Study 25 Years Old Male Patient Reason For Encounter Skin Problem [2025 LATEST] WALDEN UNIVERSITY

IHUMAN CASE STUDY WEEK 4# 25 YEARS OLD

;REASON FOR ENCOUNTER SKIN PROBLEM

**HISTORY (HPI, ROS, PMH, etc.)**

**Chief Complaint (CC):**

“I have a rash.”

**History of Present Illness (HPI):**

- **Onset:** The rash started about 3 days ago.

- **Location:** It’s mainly on my arms and torso.

- **Duration:** It’s been there consistently since it began.

- **Characteristics:** I have red, itchy patches that are slightly raised.

- **Associated symptoms:** There’s a mild burning sensation, but no fever or

other systemic symptoms.

- **Timing:** It’s constant throughout the day.

- **Exacerbating factors:** Scratching makes the irritation worse.

- **Relieving factors:** A cool compress helps ease the itching.

- **Severity:** It’s moderate and is affecting my comfort and concentration.

- **Previous episodes:** This is the first time I’ve had this rash.

**Past Medical History (PMH):**

- Generally healthy.

- No chronic illnesses.

- No previous skin conditions reported.

**Past Surgical History (PSH):**

- None.

**Medications:**

- Occasionally takes ibuprofen for menstrual cramps.

- No regular medications.

**Allergies:**

- No known drug or food allergies.

- Denies any environmental allergies.

**Family History (FH):**

- No family history of skin diseases.

- No autoimmune or allergic conditions in the family.

**Social History (SH):**

- Non-smoker.

- Drinks alcohol socially.

- No illicit drug use.

- Lives with roommates, hasn’t traveled recently.

- No new personal care products, detergents, or pets.

- Works as a barista; no exposure to irritants reported.

**Review of Systems (ROS):**

- **Skin:** Reports the rash as described above. Denies any bruising, ulceration,

or color changes elsewhere.

- **General:** Denies fever, chills, fatigue, or weight changes.

- **HEENT:** Denies sore throat, runny nose, or eye irritation.

- **Respiratory:** No shortness of breath

PHYSICAL EXAM

General:

Patient is alert and oriented to person, place, and time.

No signs of acute distress.

Appears well-nourished and well-developed.

Skin:

Notable erythematous, slightly raised plaques with some areas of scratching

observed on both forearms, upper chest, and abdomen.

No vesicles, pustules, or open wounds present.

No indications of secondary infection (no warmth, pus, or swelling).

Mild lichenification is seen in the affected areas due to scratching.

Scalp, nails, and mucous membranes are unaffected.

HEENT:

Head: Normal shape and size, no trauma.

Eyes: Conjunctivae are clear, and sclerae show no signs of jaundice.

Ears, nose, throat: No abnormalities detected.

Lymph Nodes:

No swelling in cervical, axillary, or inguinal lymph nodes.

Cardiovascular:

Heart rate and rhythm are regular.

No murmurs, rubs, or gallops detected.

Respiratory:

Lungs are clear upon examination on both sides.

No rales, wheezes, or rhonchi noted.

GI:

Abdomen is soft and non-tender.

No enlargement of the liver or spleen, and no masses found.

Neurological:

Patient is alert and oriented, with no focal deficits.

Cranial nerves II–XII appear to be functioning normally.

TEST RESULTS

Laboratory Tests:

Complete Blood Count (CBC):

WBC: Normal

Hemoglobin/Hematocrit: Normal

Platelets: Normal

→ No signs of systemic infection or inflammation

Comprehensive Metabolic Panel (CMP):

Electrolytes, BUN, Creatinine, Liver enzymes: All within normal limits

→ No metabolic issues found

Allergy Testing (if performed):

Not performed or pending in this case

Skin Scraping with KOH prep:

Negative for fungal elements

→ Rules out tinea corporis (ringworm)

Skin biopsy:

Not necessary at this time based on clinical appearance and lack of systemic

signs

Interpretation:

The test results indicate a non-infectious, non-systemic cause. The absence of

fungal elements effectively rules out tinea. The lab values are normal,

suggesting conditions like atopic dermatitis or contact dermatitis rather than

infectious or autoimmune issues.

DIAGNOSIS

Primary Diagnosis:

Atopic Dermatitis (Eczema) – Likely

Rationale:

- The classic signs are all there: itchy, red, well-defined patches.

- The rash is showing up in the usual spots for adults, like the arms and torso,

which fits the eczema profile.

- There’s some mild scratching and thickening of the skin from irritation.

- No systemic symptoms to worry about.

- Lab results came back normal, and the negative KOH test rules out any fungal

issues.

- There’s no sign of bacterial infection or psoriasis either.

Secondary/Rule-Out Diagnoses:

Contact Dermatitis (Irritant or Allergic) – Possible

- This could be a consideration if future history points to a new product or

exposure.

Psoriasis – Unlikely

- There are no silvery scales or any involvement of the nails or scalp.

Tinea Corporis (Ringworm) – Ruled out by negative KOH prep

Urticaria – Unlikely

- The lesions are persistent, not the kind that come and go or move around.

Here's a plan for therapeutic interventions: