2025 NUR 6531,"Comprehensive IHuman Case Assessment: Evaluating Hand Pain in a 16-Year-Old Male in an Outpatient Setting with SOAP Note Analysis

Course: Case2025 – 6531 Week: 9 � Patient Information: Age: 16 years old Gender: Male Height: 5'7" (170 cm) Weight: 132 lbs (60.0 kg) � Encounter Information: Reason for Encounter: Hand pain Location: Outpatient clinic o X-ray available o ECG available o Lab capabilities present � Patient History Chief Complaint (CC): "My hand hurts." History of Present Illness (HPI): The patient is a 16-year-old right-handed male presenting with a recent onset of right/left hand pain (adjust based on your case). He reports that the pain began [insert duration, e.g., ―2 days ago‖] after [insert mechanism, e.g., ―falling on an outstretched hand during a basketball game‖]. He describes the pain as: Quality: [Sharp, dull, throbbing, burning, etc.] Severity: [Mild, moderate, severe; pain scale 1–10] Location: [Specific location on the hand—e.g., dorsal, palmar, wrist, fingers] Radiation: [Yes/No; specify direction if yes] Timing: [Constant, intermittent, worsens with activity, etc.] Aggravating Factors: [Movement, pressure, writing, etc.] Relieving Factors: [Rest, ice, pain medications] Associated Symptoms: [Swelling, bruising, numbness, tingling, decreased range of motion] Past Medical History (PMH): No chronic illnesses reported No history of musculoskeletal injuries or chronic joint issues Past Surgical History (PSH): None Medications: None reported Allergies: No known drug allergies (NKDA)