Pediatric Primary Care Case Study Week 9 (Walden 6512): 16-Year-Old

PEDIATRIC PRIMARY CARE CASE STUDY - WEEK 9 (WALDEN 6512): 16-YEAR-OLD MALE WITH RIGHT HAND PAIN | SOAP NOTE, EVIDENCE-BASED PLAN & FOLLOW-UP16-Year-Old Male with Right Hand Pain 1. Chief Complaint & History of Present Illness Chief Complaint: "My right hand hurts, especially near the thumb, for the past 5 days." HPI: A 16-year-old right-hand-dominant male presents with a 5-day history of progressive pain and swelling at the base of his right thumb (radial aspect of the wrist/hand). Pain began insidiously after a weekend of extensive video gaming and texting. He describes it as a constant, dull ache with sharp exacerbations during thumb movement, particularly with gripping, pinching, or extending the thumb. Pain intensity: 6/10 at rest, increasing to 8/10 with use. He reports localized swelling and occasional "catching" or "snapping" sensation. He has tried ice and ibuprofen (400mg twice) with partial relief. No prior similar episodes. No recent trauma, fever, or systemic symptoms. 2. Past Medical, Surgical, Family & Social History PMH: Generally healthy. No chronic illnesses. Childhood vaccinations current. PSH: None. Medications: Occasional ibuprofen. No allergies. FH: Non-contributory for rheumatologic or musculoskeletal disorders. SH: 10th-grade student. Avid video gamer (reports 3-4 hours daily,increased over weekend). Frequent smartphone use.