,Patient Information
Name: Not specified (referred to as “John Doe” for clarity, per
iHuman convention)
Age: 16 years old
Gender: Male
Height: 5’8” (173 cm, based on average for adolescent males)
Weight: 150 lbs (68 kg, BMI 22.8 kg/m², normal)
Reason for Encounter: Right hand pain for 2 days
Setting: Primary care or urgent care clinic
Class: 6512, Week #4, Walden University
History of Present Illness (HPI)
John Doe, a 16-year-old Caucasian male, presents to the primary care
clinic with right hand pain for 2 days, described as a dull, aching sensation
localized to the dorsum of the right hand, primarily over the 4th and 5th
metacarpal region. He rates the pain 5/10 at rest and 7/10 with
movement (e.g., gripping a pen, attempting to make a fist, or lifting
objects). The pain began abruptly after punching a wall in frustration
during an argument with a friend, indicating a traumatic etiology.
, Associated symptoms include moderate swelling and ecchymosis over
the dorsal hand, particularly near the 5th metacarpal, and difficulty
making a full fist due to pain and stiffness. John denies numbness,
tingling, weakness, radiating pain, fever, redness, warmth, or purulent
discharge, reducing suspicion for nerve injury or infection. He reports no
prior hand injuries, chronic joint pain, or systemic symptoms (e.g.,
fatigue, weight loss, or night sweats), making inflammatory or systemic
conditions unlikely.As a varsity baseball player (pitcher), John engages in
repetitive hand and wrist motions, which could predispose him to
overuse injuries (e.g., tendonitis), though the acute, trauma-related
onset makes this less likely. He notes increased practice intensity over
the past month (10–12 hours/week), but no recent changes in technique
or equipment. John has used ibuprofen 400 mg PRN (2–3 doses over 2
days, providing ~30% pain relief) and applies ice intermittently (20
minutes every 3–4 hours, reducing swelling). He denies smoking, alcohol,
or illicit drug use, and reports moderate stress from academic pressures
and sports performance expectations, exacerbated by the recent
argument. John lives with his parents, is a high school sophomore, and
has no history of chronic medical conditions.
Onset: Acute, 2 days ago, post-traumatic (punched wall).
Name: Not specified (referred to as “John Doe” for clarity, per
iHuman convention)
Age: 16 years old
Gender: Male
Height: 5’8” (173 cm, based on average for adolescent males)
Weight: 150 lbs (68 kg, BMI 22.8 kg/m², normal)
Reason for Encounter: Right hand pain for 2 days
Setting: Primary care or urgent care clinic
Class: 6512, Week #4, Walden University
History of Present Illness (HPI)
John Doe, a 16-year-old Caucasian male, presents to the primary care
clinic with right hand pain for 2 days, described as a dull, aching sensation
localized to the dorsum of the right hand, primarily over the 4th and 5th
metacarpal region. He rates the pain 5/10 at rest and 7/10 with
movement (e.g., gripping a pen, attempting to make a fist, or lifting
objects). The pain began abruptly after punching a wall in frustration
during an argument with a friend, indicating a traumatic etiology.
, Associated symptoms include moderate swelling and ecchymosis over
the dorsal hand, particularly near the 5th metacarpal, and difficulty
making a full fist due to pain and stiffness. John denies numbness,
tingling, weakness, radiating pain, fever, redness, warmth, or purulent
discharge, reducing suspicion for nerve injury or infection. He reports no
prior hand injuries, chronic joint pain, or systemic symptoms (e.g.,
fatigue, weight loss, or night sweats), making inflammatory or systemic
conditions unlikely.As a varsity baseball player (pitcher), John engages in
repetitive hand and wrist motions, which could predispose him to
overuse injuries (e.g., tendonitis), though the acute, trauma-related
onset makes this less likely. He notes increased practice intensity over
the past month (10–12 hours/week), but no recent changes in technique
or equipment. John has used ibuprofen 400 mg PRN (2–3 doses over 2
days, providing ~30% pain relief) and applies ice intermittently (20
minutes every 3–4 hours, reducing swelling). He denies smoking, alcohol,
or illicit drug use, and reports moderate stress from academic pressures
and sports performance expectations, exacerbated by the recent
argument. John lives with his parents, is a high school sophomore, and
has no history of chronic medical conditions.
Onset: Acute, 2 days ago, post-traumatic (punched wall).
