Week 9 iHuman Case Study: Complete Clinical Assessment,
Diagnosis, and Treatment Plan for a 16-Year-Old Male With
Right Hand Pain | NURS 6531
Comprehensive Week 9 iHuman case study for NURS 6531 featuring a 16-year-old male presenting
with right hand pain. Includes detailed history, physical exam, differential diagnosis, final diagnosis,
and evidence-based treatment plan.
Course: NURS 6531 – Advanced Practice Nursing
Patient: 16-year-old Male
Chief Complaint: Right hand pain
,SUBJECTIVE
Chief Complaint (CC):
“My right hand has been hurting for the past few days.”
History of Present Illness (HPI):
The patient is a 16-year-old right-hand–dominant male who presents with right hand pain that began 3 days
ago after punching a wall during an argument. He describes the pain as sharp and throbbing, rated 6/10,
localized to the ulnar aspect of the right hand, particularly over the 4th and 5th metacarpals. Pain is
worsened with movement and gripping objects and relieved slightly by rest and ice. He reports swelling
and bruising but denies numbness, tingling, or radiation of pain. No open wounds, fever, or prior injury to
the hand reported.
Past Medical History (PMH):
• No chronic illnesses
• No prior fractures or hand injuries
Past Surgical History (PSH):
• None
Medications:
• Ibuprofen 400 mg PRN pain (took once with minimal relief)
Allergies:
• No known drug allergies (NKDA)
Family History (FH):
• Father: Hypertension
• Mother: Healthy
• No family history of bone disorders or arthritis
Social History (SH):
• High school student
• Denies tobacco, alcohol, or illicit drug use
• Lives with parents
• Active in school sports (basketball)
, Review of Systems (ROS):
• General: Denies fever, chills, weight loss
• Musculoskeletal: Reports right hand pain, swelling, decreased range of motion
• Neurologic: Denies numbness, tingling, weakness
• Skin: Bruising over right hand, no lacerations
• Cardiovascular/Respiratory: Denies chest pain, SOB
• Psychiatric: Reports recent anger episode but denies depression or self-harm ideation
OBJECTIVE
Vital Signs:
• BP: 118/72 mmHg
• HR: 78 bpm
• RR: 16 breaths/min
• Temp: 98.4°F (36.9°C)
• SpO₂: 99% on room air
Physical Examination:
General:
• Well-appearing adolescent male, in mild discomfort
Right Hand Examination:
• Inspection: Swelling and ecchymosis over the dorsum of the right hand, especially over the 5th
metacarpal
• Palpation: Tenderness over the 4th and 5th metacarpals; no open wounds
• Range of Motion: Decreased due to pain
• Strength: Reduced grip strength on the right
• Neurovascular: Sensation intact; capillary refill <2 seconds; radial pulse palpable
• Deformity: Mild angulation noted over the 5th metacarpal
Left Hand: Normal
ASSESSMENT
Primary Diagnosis:
Diagnosis, and Treatment Plan for a 16-Year-Old Male With
Right Hand Pain | NURS 6531
Comprehensive Week 9 iHuman case study for NURS 6531 featuring a 16-year-old male presenting
with right hand pain. Includes detailed history, physical exam, differential diagnosis, final diagnosis,
and evidence-based treatment plan.
Course: NURS 6531 – Advanced Practice Nursing
Patient: 16-year-old Male
Chief Complaint: Right hand pain
,SUBJECTIVE
Chief Complaint (CC):
“My right hand has been hurting for the past few days.”
History of Present Illness (HPI):
The patient is a 16-year-old right-hand–dominant male who presents with right hand pain that began 3 days
ago after punching a wall during an argument. He describes the pain as sharp and throbbing, rated 6/10,
localized to the ulnar aspect of the right hand, particularly over the 4th and 5th metacarpals. Pain is
worsened with movement and gripping objects and relieved slightly by rest and ice. He reports swelling
and bruising but denies numbness, tingling, or radiation of pain. No open wounds, fever, or prior injury to
the hand reported.
Past Medical History (PMH):
• No chronic illnesses
• No prior fractures or hand injuries
Past Surgical History (PSH):
• None
Medications:
• Ibuprofen 400 mg PRN pain (took once with minimal relief)
Allergies:
• No known drug allergies (NKDA)
Family History (FH):
• Father: Hypertension
• Mother: Healthy
• No family history of bone disorders or arthritis
Social History (SH):
• High school student
• Denies tobacco, alcohol, or illicit drug use
• Lives with parents
• Active in school sports (basketball)
, Review of Systems (ROS):
• General: Denies fever, chills, weight loss
• Musculoskeletal: Reports right hand pain, swelling, decreased range of motion
• Neurologic: Denies numbness, tingling, weakness
• Skin: Bruising over right hand, no lacerations
• Cardiovascular/Respiratory: Denies chest pain, SOB
• Psychiatric: Reports recent anger episode but denies depression or self-harm ideation
OBJECTIVE
Vital Signs:
• BP: 118/72 mmHg
• HR: 78 bpm
• RR: 16 breaths/min
• Temp: 98.4°F (36.9°C)
• SpO₂: 99% on room air
Physical Examination:
General:
• Well-appearing adolescent male, in mild discomfort
Right Hand Examination:
• Inspection: Swelling and ecchymosis over the dorsum of the right hand, especially over the 5th
metacarpal
• Palpation: Tenderness over the 4th and 5th metacarpals; no open wounds
• Range of Motion: Decreased due to pain
• Strength: Reduced grip strength on the right
• Neurovascular: Sensation intact; capillary refill <2 seconds; radial pulse palpable
• Deformity: Mild angulation noted over the 5th metacarpal
Left Hand: Normal
ASSESSMENT
Primary Diagnosis:
