,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, assumed average for adolescent male)
Weight: 150 lbs (68 kg, BMI 22.8 kg/m², normal)
Reason for Encounter: Hand pain
Setting: Primary care clinic or urgent care
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 a chief complaint of right hand pain for 2 days. He describes
the pain as a dull, aching sensation localized to the dorsum of the right
hand, rated 5/10 at rest and 7/10 with movement (e.g., gripping,
writing). The pain began after punching a wall in frustration during an
argument with a friend 2 days ago, suggesting a traumatic etiology. He
reports swelling and bruising over the dorsum of the right hand,
, particularly near the metacarpal region, and difficulty making a fist due
to pain and stiffness. John denies numbness, tingling, weakness, or
radiating pain, reducing suspicion for nerve or vascular injury. He
reports no fever, redness, warmth, or purulent discharge, making
infection less likely. He denies prior hand injuries, chronic joint pain, or
systemic symptoms (e.g., fatigue, weight loss).John is a high school
sophomore and an active varsity baseball player (pitcher), which
involves repetitive hand and wrist motions, potentially contributing to
overuse injuries. He denies recent changes in activity level but notes
increased practice intensity in the past month. He takes no regular
medications, uses ibuprofen 400 mg PRN (2–3 doses since injury, partial
relief), and applies ice intermittently (reduces swelling). He denies
smoking, alcohol, or illicit drug use. John lives with his parents and
reports moderate stress from school and sports performance
expectations.
Onset: Acute, 2 days ago, post-traumatic (punched wall).
Location: Dorsum of right hand, near metacarpals.
Duration: Continuous for 2 days, worse with movement.
Characteristics: Dull, aching, 5/10 at rest, 7/10 with motion,
associated with swelling and bruising.
Name: Not specified (referred to as “John Doe” for clarity, per
iHuman convention)
Age: 16 years old
Gender: Male
Height: 5’8” (173 cm, assumed average for adolescent male)
Weight: 150 lbs (68 kg, BMI 22.8 kg/m², normal)
Reason for Encounter: Hand pain
Setting: Primary care clinic or urgent care
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 a chief complaint of right hand pain for 2 days. He describes
the pain as a dull, aching sensation localized to the dorsum of the right
hand, rated 5/10 at rest and 7/10 with movement (e.g., gripping,
writing). The pain began after punching a wall in frustration during an
argument with a friend 2 days ago, suggesting a traumatic etiology. He
reports swelling and bruising over the dorsum of the right hand,
, particularly near the metacarpal region, and difficulty making a fist due
to pain and stiffness. John denies numbness, tingling, weakness, or
radiating pain, reducing suspicion for nerve or vascular injury. He
reports no fever, redness, warmth, or purulent discharge, making
infection less likely. He denies prior hand injuries, chronic joint pain, or
systemic symptoms (e.g., fatigue, weight loss).John is a high school
sophomore and an active varsity baseball player (pitcher), which
involves repetitive hand and wrist motions, potentially contributing to
overuse injuries. He denies recent changes in activity level but notes
increased practice intensity in the past month. He takes no regular
medications, uses ibuprofen 400 mg PRN (2–3 doses since injury, partial
relief), and applies ice intermittently (reduces swelling). He denies
smoking, alcohol, or illicit drug use. John lives with his parents and
reports moderate stress from school and sports performance
expectations.
Onset: Acute, 2 days ago, post-traumatic (punched wall).
Location: Dorsum of right hand, near metacarpals.
Duration: Continuous for 2 days, worse with movement.
Characteristics: Dull, aching, 5/10 at rest, 7/10 with motion,
associated with swelling and bruising.
