i-HUMAN WEEK#9 FULL STUDY CASE
(16-YRS-OLD MALE ACUTE HAND PAIN)
,i-Human Case Study – Week #9
Patient Introduction
• Name: [Redacted for confidentiality]
• Age: 16 years
• Sex: Male
• Presenting Complaint: Acute pain in the right hand
• Setting: Outpatient clinic
• Allergies: None reported
• Medications: None
• Occupation/School: High school student, active in sports (basketball)
History of Present Illness (HPI)
The patient is a 16-year-old male presenting with acute onset right-hand pain after a fall while playing
basketball earlier today. He reports landing directly on his outstretched right hand, experiencing
immediate pain localized to the radial side of the wrist and snuffbox area. The pain is sharp (8/10),
worsened by movement, and associated with swelling and bruising.
He denies prior hand injuries, numbness, tingling, or weakness. No open wounds were noted, but he
admits to difficulty gripping objects. No other trauma or systemic symptoms (fever, malaise) reported.
Timeline:
• 0 minutes post-injury: Fall on outstretched hand
• Immediate: Sharp pain in wrist, mild swelling
• 2 hours post-injury: Increased swelling, difficulty moving fingers
• Present: Pain persistent, localized to anatomical snuffbox, limited range of motion
Past Medical History (PMH)
• Generally healthy
• No chronic illnesses
• Immunizations up to date
• No prior fractures or musculoskeletal injuries
, Family History
• Non-contributory; no known osteoporosis, bleeding disorders, or connective tissue diseases
Social History
• Lives with parents, high school student
• Active in sports (basketball, occasional skateboarding)
• No tobacco, alcohol, or illicit drug use
Review of Systems (ROS)
System Findings
General No fever, chills, or weight loss
Musculoskeletal Acute right-hand pain, swelling, bruising, limited ROM; denies pain elsewhere
Neurologic No numbness or tingling; hand strength decreased due to pain
Vascular No coldness or color change; pulses intact
Skin Bruising over radial wrist, mild edema, no lacerations
Other systems Unremarkable
Physical Examination
Vital Signs
• Temp: 36.8°C
• HR: 82 bpm
• BP: 118/72 mmHg
• RR: 16/min
• SpO₂: 98% on room air
General Appearance
• Alert, cooperative, in mild distress due to hand pain
• No acute distress elsewhere
Focused Right-Hand/Wrist Exam
(16-YRS-OLD MALE ACUTE HAND PAIN)
,i-Human Case Study – Week #9
Patient Introduction
• Name: [Redacted for confidentiality]
• Age: 16 years
• Sex: Male
• Presenting Complaint: Acute pain in the right hand
• Setting: Outpatient clinic
• Allergies: None reported
• Medications: None
• Occupation/School: High school student, active in sports (basketball)
History of Present Illness (HPI)
The patient is a 16-year-old male presenting with acute onset right-hand pain after a fall while playing
basketball earlier today. He reports landing directly on his outstretched right hand, experiencing
immediate pain localized to the radial side of the wrist and snuffbox area. The pain is sharp (8/10),
worsened by movement, and associated with swelling and bruising.
He denies prior hand injuries, numbness, tingling, or weakness. No open wounds were noted, but he
admits to difficulty gripping objects. No other trauma or systemic symptoms (fever, malaise) reported.
Timeline:
• 0 minutes post-injury: Fall on outstretched hand
• Immediate: Sharp pain in wrist, mild swelling
• 2 hours post-injury: Increased swelling, difficulty moving fingers
• Present: Pain persistent, localized to anatomical snuffbox, limited range of motion
Past Medical History (PMH)
• Generally healthy
• No chronic illnesses
• Immunizations up to date
• No prior fractures or musculoskeletal injuries
, Family History
• Non-contributory; no known osteoporosis, bleeding disorders, or connective tissue diseases
Social History
• Lives with parents, high school student
• Active in sports (basketball, occasional skateboarding)
• No tobacco, alcohol, or illicit drug use
Review of Systems (ROS)
System Findings
General No fever, chills, or weight loss
Musculoskeletal Acute right-hand pain, swelling, bruising, limited ROM; denies pain elsewhere
Neurologic No numbness or tingling; hand strength decreased due to pain
Vascular No coldness or color change; pulses intact
Skin Bruising over radial wrist, mild edema, no lacerations
Other systems Unremarkable
Physical Examination
Vital Signs
• Temp: 36.8°C
• HR: 82 bpm
• BP: 118/72 mmHg
• RR: 16/min
• SpO₂: 98% on room air
General Appearance
• Alert, cooperative, in mild distress due to hand pain
• No acute distress elsewhere
Focused Right-Hand/Wrist Exam
