I human Case 16 Year Old Male With Hand Pain Case
Assessment Walden University Case Class
6531/Clinical Evaluation and Management of a 16-
Year Old Male with Hand Pain Following a Fall: A Case
Study on Scaphoid Fracture and Pathophysiologic
ImplIcatIons”
.
Clinical Evaluation and Management of a 16-Year-Old Male With Hand Pain Following a Fall
Case Study: Suspected Scaphoid Fracture and Pathophysiologic Implications
,Course: NRNP / NURS 6531 – Advanced Practice Care of Adults
Institution: Walden University
Patient Introduction
The patient is a 16-year-old adolescent male who presents to the outpatient clinic with right hand and
wrist pain following a fall earlier in the day. He reports worsening pain, limited wrist movement, and
swelling. The patient is right-hand dominant and has no significant past medical history. He arrives
accompanied by a parent.
Chief Complaint (CC)
“My hand hurts really bad after I fell.”
History of Present Illness (HPI)
The patient is a 16-year-old male who presents with acute right wrist and hand pain after sustaining a
fall onto an outstretched hand (FOOSH) approximately 6 hours prior to presentation while playing
basketball. He reports landing on his right hand with the wrist extended.
The pain is described as sharp and aching, localized primarily to the radial aspect of the wrist, with
radiation into the thumb. Pain severity is rated 7/10, worsened by wrist movement and gripping objects,
and partially relieved with rest. The patient reports mild swelling but denies numbness, tingling, open
wounds, or deformity.
He has not taken any medications prior to arrival. No prior wrist injuries are reported. There is no history
of fever, systemic symptoms, or recent illness.
Past Medical History (PMH)
• No chronic medical conditions
• No previous fractures or orthopedic injuries
Past Surgical History (PSH)
• None
Medications
• None
, Allergies
• No known drug allergies (NKDA)
Family History
• No family history of bone disorders, osteoporosis, or autoimmune disease
Social History
• High school student
• Participates in recreational sports (basketball)
• Denies tobacco, alcohol, or illicit drug use
• Lives at home with parents
Review of Systems (ROS)
General:
• Denies fever, chills, weight loss, or fatigue
Musculoskeletal:
• Positive for right wrist pain, swelling, decreased range of motion
• Denies pain in other joints
Neurologic:
• Denies numbness, tingling, or weakness
Skin:
• Denies open wounds, bruising, or discoloration
Cardiovascular/Respiratory:
• Denies chest pain, shortness of breath
All other systems reviewed and are negative.
Physical Examination
Vital Signs
Assessment Walden University Case Class
6531/Clinical Evaluation and Management of a 16-
Year Old Male with Hand Pain Following a Fall: A Case
Study on Scaphoid Fracture and Pathophysiologic
ImplIcatIons”
.
Clinical Evaluation and Management of a 16-Year-Old Male With Hand Pain Following a Fall
Case Study: Suspected Scaphoid Fracture and Pathophysiologic Implications
,Course: NRNP / NURS 6531 – Advanced Practice Care of Adults
Institution: Walden University
Patient Introduction
The patient is a 16-year-old adolescent male who presents to the outpatient clinic with right hand and
wrist pain following a fall earlier in the day. He reports worsening pain, limited wrist movement, and
swelling. The patient is right-hand dominant and has no significant past medical history. He arrives
accompanied by a parent.
Chief Complaint (CC)
“My hand hurts really bad after I fell.”
History of Present Illness (HPI)
The patient is a 16-year-old male who presents with acute right wrist and hand pain after sustaining a
fall onto an outstretched hand (FOOSH) approximately 6 hours prior to presentation while playing
basketball. He reports landing on his right hand with the wrist extended.
The pain is described as sharp and aching, localized primarily to the radial aspect of the wrist, with
radiation into the thumb. Pain severity is rated 7/10, worsened by wrist movement and gripping objects,
and partially relieved with rest. The patient reports mild swelling but denies numbness, tingling, open
wounds, or deformity.
He has not taken any medications prior to arrival. No prior wrist injuries are reported. There is no history
of fever, systemic symptoms, or recent illness.
Past Medical History (PMH)
• No chronic medical conditions
• No previous fractures or orthopedic injuries
Past Surgical History (PSH)
• None
Medications
• None
, Allergies
• No known drug allergies (NKDA)
Family History
• No family history of bone disorders, osteoporosis, or autoimmune disease
Social History
• High school student
• Participates in recreational sports (basketball)
• Denies tobacco, alcohol, or illicit drug use
• Lives at home with parents
Review of Systems (ROS)
General:
• Denies fever, chills, weight loss, or fatigue
Musculoskeletal:
• Positive for right wrist pain, swelling, decreased range of motion
• Denies pain in other joints
Neurologic:
• Denies numbness, tingling, or weakness
Skin:
• Denies open wounds, bruising, or discoloration
Cardiovascular/Respiratory:
• Denies chest pain, shortness of breath
All other systems reviewed and are negative.
Physical Examination
Vital Signs
