Actual and accurate i-Human Case Study: 16-Year-Old
Male With Hand Pain | NURS 6531 Walden University
– Advanced Practice Assessment
•
• History & HPI
• ROS
• PE
• Most-asked questions
• Diagnosis + rationale
, • Treatment plan
• SOAP note
• Follow-up plan
• PowerPoint outline
History
Chief Complaint (CC):
“My right hand has been hurting since I fell while skateboarding two
days ago.”
History of Present Illness (HPI):
16-year-old right-hand–dominant male presents with pain and
swelling in his right hand after falling on an outstretched hand
during skateboarding two days ago.
• Onset: Sudden, after fall.
• Location: Dorsal aspect of right hand, near base of 4th and 5th
metacarpals.
• Duration: 2 days.
• Character: Throbbing, aching pain, worsens with gripping or
finger movement.
• Aggravating factors: Gripping objects, flexing fingers.
• Relieving factors: Rest, ice, elevation.
• Associated symptoms: Mild bruising and swelling.
• Denies: Numbness, tingling, weakness, deformity, open wounds,
fever, chills.
• Functional impact: Difficulty writing and playing basketball.
Past Medical History: None significant.
Past Surgical History: None.
, Medications: Occasional acetaminophen for pain.
Allergies: NKDA.
Family History: Unremarkable.
Social History: High school student; active in sports; denies tobacco,
alcohol, or drug use.
Review of Systems (ROS)
• General: No fever, chills, or fatigue.
• Skin: (+) Bruising over right hand; no lacerations or rash.
• Musculoskeletal: (+) Right hand pain, swelling, limited
movement. No elbow or shoulder pain.
• Neurological: No numbness, tingling, or weakness.
• Cardiovascular: No color changes or coolness in extremity.
• Respiratory, GI, GU: Negative.
Physical Examination (PE)
Vitals:
• BP: 110/68 mmHg
• HR: 82 bpm
• RR: 18/min
• Temp: 98.4°F (36.9°C)
• SpO₂: 99% RA
General: Alert, cooperative, appears uncomfortable with right-hand
use.
Skin: Ecchymosis and mild swelling over dorsum of right hand.
Musculoskeletal:
• Tenderness over 4th–5th metacarpal region.
Male With Hand Pain | NURS 6531 Walden University
– Advanced Practice Assessment
•
• History & HPI
• ROS
• PE
• Most-asked questions
• Diagnosis + rationale
, • Treatment plan
• SOAP note
• Follow-up plan
• PowerPoint outline
History
Chief Complaint (CC):
“My right hand has been hurting since I fell while skateboarding two
days ago.”
History of Present Illness (HPI):
16-year-old right-hand–dominant male presents with pain and
swelling in his right hand after falling on an outstretched hand
during skateboarding two days ago.
• Onset: Sudden, after fall.
• Location: Dorsal aspect of right hand, near base of 4th and 5th
metacarpals.
• Duration: 2 days.
• Character: Throbbing, aching pain, worsens with gripping or
finger movement.
• Aggravating factors: Gripping objects, flexing fingers.
• Relieving factors: Rest, ice, elevation.
• Associated symptoms: Mild bruising and swelling.
• Denies: Numbness, tingling, weakness, deformity, open wounds,
fever, chills.
• Functional impact: Difficulty writing and playing basketball.
Past Medical History: None significant.
Past Surgical History: None.
, Medications: Occasional acetaminophen for pain.
Allergies: NKDA.
Family History: Unremarkable.
Social History: High school student; active in sports; denies tobacco,
alcohol, or drug use.
Review of Systems (ROS)
• General: No fever, chills, or fatigue.
• Skin: (+) Bruising over right hand; no lacerations or rash.
• Musculoskeletal: (+) Right hand pain, swelling, limited
movement. No elbow or shoulder pain.
• Neurological: No numbness, tingling, or weakness.
• Cardiovascular: No color changes or coolness in extremity.
• Respiratory, GI, GU: Negative.
Physical Examination (PE)
Vitals:
• BP: 110/68 mmHg
• HR: 82 bpm
• RR: 18/min
• Temp: 98.4°F (36.9°C)
• SpO₂: 99% RA
General: Alert, cooperative, appears uncomfortable with right-hand
use.
Skin: Ecchymosis and mild swelling over dorsum of right hand.
Musculoskeletal:
• Tenderness over 4th–5th metacarpal region.
