Comprehensive i-Human Week #9 Case (NR 6512) 16-Year-Old
Male with Right Hand Pain Detailed Report & Analysis UPDATED
2026 WALDEN UNIVERSITY
,Comprehensive iHuman SOAP Case Study
Week #4 (Class 6550)
Pediatric Patient: 16-Year-Old With Cough and Trouble Breathing
Patient Identification
• Age: 16 years
• Gender: Male
• Ethnicity: Not specified
• Source of Information: Mother (primary caregiver; reliable historian)
• Chief Complaint (CC): “My child has been coughing and is having
trouble breathing.”
S – Subjective Data
History of Present Illness (HPI)
The patient is a 16-year-old male who presents with a 3-day history of
progressive cough and increasing difficulty breathing. According to the
mother, symptoms began with a mild dry cough and nasal congestion. Over
the past 24 hours, the cough has become more frequent and productive of
small amounts of clear mucus. The mother reports worsening shortness of
, breath, rapid breathing, and audible wheezing, particularly at night and with
physical activity.
She has observed nasal flaring and chest retractions, indicating increased
work of breathing. The child has experienced intermittent low-grade fever,
with the highest recorded temperature of 100.8°F (38.2°C). Appetite has
decreased, and the child is more fatigued and less playful than usual.
Albuterol inhaler was administered twice at home with partial but
temporary relief.
No history of choking, foreign body aspiration, chest pain, vomiting,
diarrhea, or rash. No known exposure to individuals with severe respiratory
illness. No recent travel.
Symptom Analysis (OLDCART)
Onset: Acute; began immediately after punching a wall, 2 days ago
Location: Dorsal ulnar aspect of the right hand, over the 4th–5th metacarpal
region
Duration: Constant since onset
Characteristics: Throbbing, sharp pain with swelling and bruising
Aggravating Factors: Finger movement, gripping objects, making a fist
Relieving Factors: Rest, elevation, ibuprofen
Timing: Persistent throughout the day
Severity: 7/10
•
Male with Right Hand Pain Detailed Report & Analysis UPDATED
2026 WALDEN UNIVERSITY
,Comprehensive iHuman SOAP Case Study
Week #4 (Class 6550)
Pediatric Patient: 16-Year-Old With Cough and Trouble Breathing
Patient Identification
• Age: 16 years
• Gender: Male
• Ethnicity: Not specified
• Source of Information: Mother (primary caregiver; reliable historian)
• Chief Complaint (CC): “My child has been coughing and is having
trouble breathing.”
S – Subjective Data
History of Present Illness (HPI)
The patient is a 16-year-old male who presents with a 3-day history of
progressive cough and increasing difficulty breathing. According to the
mother, symptoms began with a mild dry cough and nasal congestion. Over
the past 24 hours, the cough has become more frequent and productive of
small amounts of clear mucus. The mother reports worsening shortness of
, breath, rapid breathing, and audible wheezing, particularly at night and with
physical activity.
She has observed nasal flaring and chest retractions, indicating increased
work of breathing. The child has experienced intermittent low-grade fever,
with the highest recorded temperature of 100.8°F (38.2°C). Appetite has
decreased, and the child is more fatigued and less playful than usual.
Albuterol inhaler was administered twice at home with partial but
temporary relief.
No history of choking, foreign body aspiration, chest pain, vomiting,
diarrhea, or rash. No known exposure to individuals with severe respiratory
illness. No recent travel.
Symptom Analysis (OLDCART)
Onset: Acute; began immediately after punching a wall, 2 days ago
Location: Dorsal ulnar aspect of the right hand, over the 4th–5th metacarpal
region
Duration: Constant since onset
Characteristics: Throbbing, sharp pain with swelling and bruising
Aggravating Factors: Finger movement, gripping objects, making a fist
Relieving Factors: Rest, elevation, ibuprofen
Timing: Persistent throughout the day
Severity: 7/10
•
