Comprehensive i-Human Week #9 Case (Class
6512): 16-Year-Old Male with Right Hand Pain –
Complete Clinical Assessment, Diagnosis,
Treatment, SOAP Note, Patient Education &
Follow-Up (Walden University 2026)
, Patient Introduction
Patient: John Doe (pseudonym)
Age/Sex: 16-year-old male
Chief Complaint: "My right hand has been hurting since I fell while playing basketball yesterday."
Setting: Outpatient clinic with lab capabilities
Relevant History: Healthy adolescent, no chronic illnesses, no allergies, up-to-date on immunizations.
History of Present Illness (HPI)
• Onset: Pain started after falling onto outstretched right hand while playing basketball ~24 hours
ago.
• Location: Dorsal aspect of the right hand, primarily around the metacarpophalangeal (MCP)
joints.
• Duration: Constant since injury
• Character: Sharp, throbbing
• Severity: 6/10 at rest, 8/10 with movement or gripping
• Aggravating Factors: Movement, gripping objects, lifting
• Relieving Factors: Rest, ice
• Associated Symptoms: Mild swelling, bruising, slight stiffness; denies numbness or tingling
• Prior Treatment: Ice and over-the-counter acetaminophen
Past Medical History (PMH): No chronic illnesses, no previous hand injuries
Surgical History (PSH): None
Medications: Occasional acetaminophen
Allergies: NKDA
Family History: Non-contributory
Social History: High school student, active in sports, denies tobacco/alcohol/illicit drug use
Review of Systems (ROS)
System Findings
General No fever, no weight loss
6512): 16-Year-Old Male with Right Hand Pain –
Complete Clinical Assessment, Diagnosis,
Treatment, SOAP Note, Patient Education &
Follow-Up (Walden University 2026)
, Patient Introduction
Patient: John Doe (pseudonym)
Age/Sex: 16-year-old male
Chief Complaint: "My right hand has been hurting since I fell while playing basketball yesterday."
Setting: Outpatient clinic with lab capabilities
Relevant History: Healthy adolescent, no chronic illnesses, no allergies, up-to-date on immunizations.
History of Present Illness (HPI)
• Onset: Pain started after falling onto outstretched right hand while playing basketball ~24 hours
ago.
• Location: Dorsal aspect of the right hand, primarily around the metacarpophalangeal (MCP)
joints.
• Duration: Constant since injury
• Character: Sharp, throbbing
• Severity: 6/10 at rest, 8/10 with movement or gripping
• Aggravating Factors: Movement, gripping objects, lifting
• Relieving Factors: Rest, ice
• Associated Symptoms: Mild swelling, bruising, slight stiffness; denies numbness or tingling
• Prior Treatment: Ice and over-the-counter acetaminophen
Past Medical History (PMH): No chronic illnesses, no previous hand injuries
Surgical History (PSH): None
Medications: Occasional acetaminophen
Allergies: NKDA
Family History: Non-contributory
Social History: High school student, active in sports, denies tobacco/alcohol/illicit drug use
Review of Systems (ROS)
System Findings
General No fever, no weight loss
