“i-Human Case: 66F with Left Hip Pain
and Inability to Bear Weight – 66-Year-
Old feMale Presenting with Back Pain |
COMPLETE A+ SOLUTION | SOAP Notes,
HPI, ROS, Physical Exam, Imaging,
Differential Diagnosis & Evidence-Based
Management Plan
,1. Patient Introduction
Mrs. Eleanor Vance is a 66-year-old female who presents to the outpatient
clinic with a chief complaint of gradual onset bilateral hand pain and
stiffness for the past 3 months, worsening over the last 2 weeks. She
reports difficulty opening jars, buttoning shirts, and gripping her coffee
mug in the morning. She has x-ray laboratory capabilities available on-site.
Part 1: Greeting & Chief Complaint
Clinician: Good morning, Mrs. Vance. Thank you for coming in today. What
brings you to the clinic?
Patient: Good morning, doctor. It's my hands. They've been hurting for a
few months now, and it's getting worse. I can barely do the things I used to
do.
Clinician: I'm sorry to hear that. Can you tell me exactly when this started?
Patient: About three months ago, maybe a little longer. It came on slowly.
At first, I thought it was just arthritis from getting older, but now it's
affecting everything I do.
Clinician: Did something specific happen when it started – like an injury or
a fall?
Patient: No, nothing like that. I just woke up one morning and my hands
felt stiff and achy. I figured it would go away, but it never did.
Part 2: HPI – Pain Characteristics
, Clinician: Where exactly in your hands do you feel the pain?
Patient: Mostly in my knuckles – the ones in the middle of my fingers and
the ones where my fingers meet my hand. Also my wrists, both of them.
Clinician: Is the pain on both hands, or just one?
Patient: Both hands, the same. It's very symmetrical.
Clinician: Can you describe the quality of the pain? Is it sharp, dull, burning,
throbbing?
Patient: It's more of a deep ache. And my hands feel stiff and swollen, even
if they don't look very swollen to other people.
Clinician: On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain
imaginable, what number would you give it?
Patient: When I'm resting, maybe a 4. But when I try to grip something like
a coffee mug or open a jar, it goes up to a 7 or 8.
Clinician: What time of day is the pain worst?
Patient: Definitely in the morning. When I wake up, I can barely make a fist.
It takes me about an hour – sometimes longer – before my hands loosen
up.
Clinician: So the stiffness lasts more than an hour in the morning?
Patient: Oh yes. At least an hour. Sometimes 90 minutes.
Part 3: HPI – Aggravating & Alleviating Factors
Clinician: What makes the pain worse?
and Inability to Bear Weight – 66-Year-
Old feMale Presenting with Back Pain |
COMPLETE A+ SOLUTION | SOAP Notes,
HPI, ROS, Physical Exam, Imaging,
Differential Diagnosis & Evidence-Based
Management Plan
,1. Patient Introduction
Mrs. Eleanor Vance is a 66-year-old female who presents to the outpatient
clinic with a chief complaint of gradual onset bilateral hand pain and
stiffness for the past 3 months, worsening over the last 2 weeks. She
reports difficulty opening jars, buttoning shirts, and gripping her coffee
mug in the morning. She has x-ray laboratory capabilities available on-site.
Part 1: Greeting & Chief Complaint
Clinician: Good morning, Mrs. Vance. Thank you for coming in today. What
brings you to the clinic?
Patient: Good morning, doctor. It's my hands. They've been hurting for a
few months now, and it's getting worse. I can barely do the things I used to
do.
Clinician: I'm sorry to hear that. Can you tell me exactly when this started?
Patient: About three months ago, maybe a little longer. It came on slowly.
At first, I thought it was just arthritis from getting older, but now it's
affecting everything I do.
Clinician: Did something specific happen when it started – like an injury or
a fall?
Patient: No, nothing like that. I just woke up one morning and my hands
felt stiff and achy. I figured it would go away, but it never did.
Part 2: HPI – Pain Characteristics
, Clinician: Where exactly in your hands do you feel the pain?
Patient: Mostly in my knuckles – the ones in the middle of my fingers and
the ones where my fingers meet my hand. Also my wrists, both of them.
Clinician: Is the pain on both hands, or just one?
Patient: Both hands, the same. It's very symmetrical.
Clinician: Can you describe the quality of the pain? Is it sharp, dull, burning,
throbbing?
Patient: It's more of a deep ache. And my hands feel stiff and swollen, even
if they don't look very swollen to other people.
Clinician: On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain
imaginable, what number would you give it?
Patient: When I'm resting, maybe a 4. But when I try to grip something like
a coffee mug or open a jar, it goes up to a 7 or 8.
Clinician: What time of day is the pain worst?
Patient: Definitely in the morning. When I wake up, I can barely make a fist.
It takes me about an hour – sometimes longer – before my hands loosen
up.
Clinician: So the stiffness lasts more than an hour in the morning?
Patient: Oh yes. At least an hour. Sometimes 90 minutes.
Part 3: HPI – Aggravating & Alleviating Factors
Clinician: What makes the pain worse?
