16-Year-Old Male Presenting
With Hand Pain – iHuman Case
Week #9 Walden University,
Exams of Nursing
Details
Category
Patient ID Confidential
Age 16 years
Sex Male
Height 170 cm
Weight 60 kg (132 lbs)
Encounter Reason Heart palpitations
Outpatient clinic (with X-ray, ECG, lab
Location
facilities)
Chief Complaint “My heart feels like it’s racing.”
Onset Sudden onset, intermittent episodes
Associated Symptoms Palpitations, possible dizziness, mild shortness
, Details
Category
of breath
Past Medical
Not specified (assumed none significant)
History
Medication History None reported
Allergies None known
Vital Signs May show increased heart rate (tachycardia)
Physical Exam Rapid pulse, otherwise normal exam
Initial Tests ECG, blood tests, possibly chest X-ray
Differential
Anxiety, arrhythmia, anemia, hyperthyroidism
Diagnosis
Provisional Likely cardiac arrhythmia (e.g., supraventricular
Diagnosis tachycardia)
ECG monitoring, labs, lifestyle advice, possible
Management Plan
referral
Generally good with proper diagnosis and
Prognosis
management
SOAP Notes
S – Subjective
16-year-old male presents with heart palpitations
Describes sensation as “racing heartbeat”
Episodes are sudden and intermittent
May be associated with:
o
With Hand Pain – iHuman Case
Week #9 Walden University,
Exams of Nursing
Details
Category
Patient ID Confidential
Age 16 years
Sex Male
Height 170 cm
Weight 60 kg (132 lbs)
Encounter Reason Heart palpitations
Outpatient clinic (with X-ray, ECG, lab
Location
facilities)
Chief Complaint “My heart feels like it’s racing.”
Onset Sudden onset, intermittent episodes
Associated Symptoms Palpitations, possible dizziness, mild shortness
, Details
Category
of breath
Past Medical
Not specified (assumed none significant)
History
Medication History None reported
Allergies None known
Vital Signs May show increased heart rate (tachycardia)
Physical Exam Rapid pulse, otherwise normal exam
Initial Tests ECG, blood tests, possibly chest X-ray
Differential
Anxiety, arrhythmia, anemia, hyperthyroidism
Diagnosis
Provisional Likely cardiac arrhythmia (e.g., supraventricular
Diagnosis tachycardia)
ECG monitoring, labs, lifestyle advice, possible
Management Plan
referral
Generally good with proper diagnosis and
Prognosis
management
SOAP Notes
S – Subjective
16-year-old male presents with heart palpitations
Describes sensation as “racing heartbeat”
Episodes are sudden and intermittent
May be associated with:
o
