Class 6512): 16-Year-Old Male with
Right Hand Pain – Complete Clinical
Assessment, Diagnosis, Treatment, SOAP
Note, Patient Education & Follow-Up
(Walden University 2026)”
Week 9 Case Report – Class 6512
Patient: 16-year-old male
Chief Complaint: Right hand pain
1. Patient Introduction
• Name: [Redacted for privacy]
, • Age: 16 years
• Sex: Male
• Presenting Complaint: Pain in the right hand for the past 2 days after a minor fall during
basketball practice.
• Past Medical History: No chronic illnesses; no previous fractures.
• Medications: None
• Allergies: No known drug allergies
• Family History: Non-contributory for musculoskeletal disorders
• Social History: Active in sports; non-smoker; no alcohol or drug use
2. History of Present Illness (HPI)
• Patient reports acute onset of pain in the right hand, particularly around the
metacarpophalangeal joint of the index finger, after falling on an outstretched hand during
basketball.
• Pain is sharp, localized, worsened by movement or gripping, and moderate intensity (6/10).
• Denies numbness, tingling, or weakness in the fingers.
• No swelling initially; mild swelling observed today.
• No prior history of trauma to this hand.
3. Review of Systems (ROS)
System Findings
Musculoskeletal Pain in right hand, mild swelling, decreased grip strength; no other joints affected
Neurologic No numbness, tingling, or motor deficits
Cardiovascular No chest pain, palpitations
Respiratory No shortness of breath
GI/GU No complaints
Skin No bruising or rashes except mild erythema over injury site
General No fever, fatigue, or weight loss
Right Hand Pain – Complete Clinical
Assessment, Diagnosis, Treatment, SOAP
Note, Patient Education & Follow-Up
(Walden University 2026)”
Week 9 Case Report – Class 6512
Patient: 16-year-old male
Chief Complaint: Right hand pain
1. Patient Introduction
• Name: [Redacted for privacy]
, • Age: 16 years
• Sex: Male
• Presenting Complaint: Pain in the right hand for the past 2 days after a minor fall during
basketball practice.
• Past Medical History: No chronic illnesses; no previous fractures.
• Medications: None
• Allergies: No known drug allergies
• Family History: Non-contributory for musculoskeletal disorders
• Social History: Active in sports; non-smoker; no alcohol or drug use
2. History of Present Illness (HPI)
• Patient reports acute onset of pain in the right hand, particularly around the
metacarpophalangeal joint of the index finger, after falling on an outstretched hand during
basketball.
• Pain is sharp, localized, worsened by movement or gripping, and moderate intensity (6/10).
• Denies numbness, tingling, or weakness in the fingers.
• No swelling initially; mild swelling observed today.
• No prior history of trauma to this hand.
3. Review of Systems (ROS)
System Findings
Musculoskeletal Pain in right hand, mild swelling, decreased grip strength; no other joints affected
Neurologic No numbness, tingling, or motor deficits
Cardiovascular No chest pain, palpitations
Respiratory No shortness of breath
GI/GU No complaints
Skin No bruising or rashes except mild erythema over injury site
General No fever, fatigue, or weight loss
