Right Hand Pain – SOAP Note & Assessment latest
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, NURS 6512 Week 9 i-Human: 16-Year-Old Male With Right Hand Pain – SOAP Note &
Comprehensive Assessment
SOAP NOTE
My right-hand hurts and is swollen after football practice.
History of Present Illness (HPI)
The patient is a 16-year-old male presenting with right hand pain that started approximately 24
hours ago after football practice. The patient states he punched another player’s helmet
accidentally while attempting a tackle. He reports immediate pain over the outer portion of the
right hand followed by swelling and difficulty gripping objects.
Pain is described as sharp and throbbing, rated 7/10 in severity, worsened by movement and
gripping activities. The patient reports mild bruising and swelling but denies numbness, tingling,
open wounds, or loss of consciousness. Ice application provided minimal relief.
Using the OLDCARTS framework:
• Onset: Yesterday during football practice
• Location: Right lateral hand near the 5th metacarpal
• Duration: Constant since injury
• Character: Sharp, throbbing pain
• Aggravating factors: Movement, gripping
• Relieving factors: Rest and ice slightly improve symptoms
• Timing: Persistent
• Severity: 7/10