History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Differential Diagnosis
Next Steps
Test Results
Diagnosis
Treatment Orders
Question 1
Question 2
Question 3
Question 4
About the Case
Back Discomfort in a 12-Year-Old Boy
Physical Examination
General appearance
: African-American male child in no apparent discomfort, normal build and appearance.
Height
: 160 cm (92nd percentile), Weight: 40 kgs (47th percentile)
Vital signs
:
Temperature: 37° C
Pulse: 80 beats/min
BP: 105/66 mm Hg
Respirations: 16/min
Skin
: No lesions or abnormal markings.
HEENT
: Moist mucous membranes, normal dentition, no caries. Eye examination and vision normal bilaterally. Hearing grossly normal.
Pulmonary
: Lungs clear to auscultation bilaterally. No chest deformity.
Cardiovascular
: Regular rate and rhythm, no murmurs, rubs, or gallops
Gastrointestinal
: Abdomen soft, nontender, nondistended.
Genitourinary
: Normal male genitalia Tanner Stage 3, testes descended bilaterally.
Musculoskeletal
: Back has mild paraspinous tenderness bilaterally in the thoracic region. When patient bends forward at the waist with his arms hanging and palms together, his shoulders are not level and his scapulae appear asymmetric. Palpation of the spinous processes show slight right thoracic and left lumbar curvature. There is no leg-length discrepancy, and iliac crests are symmetrical. Extremities have full range of motion, no visible or palpable deformities or tenderness of extremities or joints.
Neurologic
: Alert and oriented to person, place, and time. Normal patellar relaxes 2+ bilaterally, 5/5 motor strength in bilateral upper and lower extremities. Normal gait. No clonus. No strictures or rigidity in the extremities.
Mental status
: Appropriate affect and behavior.
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