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
Review of Systems
General
: Patient feels well except for occasional upper back pain and stiffness. No fever, chills, or night sweats. No weight loss or change in appetite. He is not yet shaving, and his voice has not yet changed.
Skin
: Mild acne, no other rash or lesions.
HEENT
: No vision changes, ear pain, hearing changes, neck stiffness, or pain in the throat.
Pulmonary
: No shortness of breath or cough.
Cardiovascular
: No chest pain or pressure.
Gastrointestinal
: No diarrhea, vomiting, or abdominal pain. Normal bowel movement once a day.
Genitourinary
: No dysuria or increased urinary frequency.
Musculoskeletal
: Positive for intermittent upper back stiffness and discomfort. No joint swelling or discomfort.
Neurologic
: No numbness, tingling, or pain running down his arms or legs. No weakness or gait changes. No difficulty controlling bladder or bowels.
Psychiatric
: No depression, psychosis, or hyperactivity.
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