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Week 9 i-Human Case Study –16 Years Old Male With Hand Pain| Complete Assessment, Diagnosis & SOAP Note (2026 Update)

HEAL100 Health Care — exam and revision material · Other

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Health Care exam material, 13 pages. Originally published on StudyMerit.

Pages
13
Academic year
2025/2026
Language
English

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Comprehensive i - Human Case S tudy: Week 9 Evaluation and Management of Knee Pain in an 83 - Year - Old Female Setting: Outpatient Primary Care Clinic Date: 2025 1. Patient Profile Age: 83 years Sex: Female Ethnicity: Caucasian M arital Status: Widowed

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Living Situation: Lives independently in a single - story home; uses a cane for ambulation Occupation: Retired elementary school teacher Insurance: Medicare 2. Chief Complaint “My right knee has been hurting for the past few weeks, and it’s getting harder to walk.” 3. History of Present Illness (HPI) S he reports gradual onset of right knee pain over the past 4 – 6 weeks. The pain is aching and stiff , rated 6/1 0 , worsened by walking and climbing stairs, and improves somewhat with rest . No history of recent trauma, twisting injury, or fall. She reports mild swelling around the knee and occasional crepitus when bending. No redness or warmth. She has not noticed lo cking, catching, or giving way. She has been using over - the - counter acetaminophen (500 mg twice daily) with partial relief. No use of NSAIDs due to prior gastritis. 4 . Review of Systems General: Denies fever, chills, or weight loss. Musculoskeletal: Right knee pain and stiffness, no pain in other joints. Neurologic: Denies numbness, tingling, or weakness. Cardiovascular: Denies chest pain, palpitations, or edema. Respiratory: No shortness of breath or cough. GI/GU: No abdominal pain, nausea, or urinary issues.

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5. Past Medical History  Hypertension (controlled on lisinopril 10 mg daily)  Hyperlipidemia (on atorvastatin 20 mg nightly)  Osteopenia (DEXA 2023: T - score −1.8)  GERD (managed with omeprazole)  No history of gout or rheumatoid arthritis 6. Past Surgical History  Right total hip replacement (2015)  Appendectomy (childhood) 7. Family History  Mother : Osteoarthritis  Father: Coronary artery disease  Brother: Type 2 diabetes 8. Social History  Non - smoker, no alcohol use  Walks daily with cane for mobility  Diet: Balanced, low sodium  No recreational drug use 9. Allergies

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