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i human case study Week #9 16-Year-Old Male with
Right Hand Pain – Complete Clinical Assessment,
Diagnosis, Treatment, SOAP Note, Patient Education &
Follow-Up REAL (Walden University 2026)
possible reasons for hand discomfor t. Pain can originate
from various sources, including the bones, ligament s,
tendons, nerves, skin, and oNther supporting tissues that
enable the hands to perform a variety of functions.
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History of Present Illness (HPI)
Section Clinician Question Patient Response
HPI How can I help you today? Well, my right hand really
hurts.
HPI When did your hand pain It started about three days
start? ago.
HPI Can you tell me what you I was playing basketball and
were doing when it started? fell, landing on my right hand.
HPI Where exactly is the pain Mostly on the back of my right
located? hand, near my knuckles.
HPI Which fingers are affected? Mostly my index and middle
fingers.
HPI How would you describe It’s mostly aching, but
the pain? sometimes it feels sharp when
I move it.
HPI How severe is the pain on a About a 6 when resting, but up
scale of 0 to 10? to an 8 when I use it.
HPI Is the pain constant or does It’s pretty constant, but worse
it come and go? when I move my hand.
HPI Does the pain travel No, it stays in my hand.
anywhere else?
HPI What makes the pain Writing, gripping things, or
worse? making a fist.
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HPI What makes the pain Resting it and putting ice on it
better? helps a little.
HPI Have you noticed any Yes, my hand looks a little
swelling? swollen.
HPI Any redness or warmth? No redness or warmth that
I’ve noticed.
HPI Do you have stiffness in Yes, especially in the morning
your hand or fingers? or after not moving it.
HPI Any numbness or tingling? No, none at all.
HPI Have you noticed weakness It feels weaker because it
in your hand? hurts, but I can still move it.
HPI Did you hear or feel a pop No, I didn’t hear or feel
when you fell? anything like that.
HPI Have you injured this hand No, this is the first time.
before?
HPI Have you tried any I used ice and took ibuprofen,
treatments? which helped a little.
HPI Is the pain affecting your Yes, it’s hard to write at school
daily activities? and play sports.
HPI Do you have any fever or No, none.
chills?
HPI Are you concerned about anything in I’m worried it might be broken.
particular?
Given the complexity of the hand’s structure, there are numerous possible reasons for hand discomfort. Pain
can originate from various sources, including the bones, ligaments, tendons, nerves, skin, and other
supporting tissues that enable the hands to perform a variety of functions.
Document shared on https://www.docsity.com/en/docs/i-human-case-study-week-9-16-year-old-male-with-right-hand-pain-complete-clinical/15576780/
i human case study Week #9 16-Year-Old Male with
Right Hand Pain – Complete Clinical Assessment,
Diagnosis, Treatment, SOAP Note, Patient Education &
Follow-Up REAL (Walden University 2026)
possible reasons for hand discomfor t. Pain can originate
from various sources, including the bones, ligament s,
tendons, nerves, skin, and oNther supporting tissues that
enable the hands to perform a variety of functions.
Document shared on https://www.docsity.com/en/docs/i-human-case-study-week-9-16-year-old-male-with-right-hand-pain-complete-clinical/15576780/
,2|Page
History of Present Illness (HPI)
Section Clinician Question Patient Response
HPI How can I help you today? Well, my right hand really
hurts.
HPI When did your hand pain It started about three days
start? ago.
HPI Can you tell me what you I was playing basketball and
were doing when it started? fell, landing on my right hand.
HPI Where exactly is the pain Mostly on the back of my right
located? hand, near my knuckles.
HPI Which fingers are affected? Mostly my index and middle
fingers.
HPI How would you describe It’s mostly aching, but
the pain? sometimes it feels sharp when
I move it.
HPI How severe is the pain on a About a 6 when resting, but up
scale of 0 to 10? to an 8 when I use it.
HPI Is the pain constant or does It’s pretty constant, but worse
it come and go? when I move my hand.
HPI Does the pain travel No, it stays in my hand.
anywhere else?
HPI What makes the pain Writing, gripping things, or
worse? making a fist.
Document shared on https://www.docsity.com/en/docs/i-human-case-study-week-9-16-year-old-male-with-right-hand-pain-complete-clinical/15576780/
,Document shared on https://www.docsity.com/en/docs/i-human-case-study-week-9-16-year-old-male-with-right-hand-pain-complete-clinical/15576780/
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HPI What makes the pain Resting it and putting ice on it
better? helps a little.
HPI Have you noticed any Yes, my hand looks a little
swelling? swollen.
HPI Any redness or warmth? No redness or warmth that
I’ve noticed.
HPI Do you have stiffness in Yes, especially in the morning
your hand or fingers? or after not moving it.
HPI Any numbness or tingling? No, none at all.
HPI Have you noticed weakness It feels weaker because it
in your hand? hurts, but I can still move it.
HPI Did you hear or feel a pop No, I didn’t hear or feel
when you fell? anything like that.
HPI Have you injured this hand No, this is the first time.
before?
HPI Have you tried any I used ice and took ibuprofen,
treatments? which helped a little.
HPI Is the pain affecting your Yes, it’s hard to write at school
daily activities? and play sports.
HPI Do you have any fever or No, none.
chills?
HPI Are you concerned about anything in I’m worried it might be broken.
particular?
Given the complexity of the hand’s structure, there are numerous possible reasons for hand discomfort. Pain
can originate from various sources, including the bones, ligaments, tendons, nerves, skin, and other
supporting tissues that enable the hands to perform a variety of functions.
Document shared on https://www.docsity.com/en/docs/i-human-case-study-week-9-16-year-old-male-with-right-hand-pain-complete-clinical/15576780/
