Denies any wounds, lumps, or pain. Denies vision issues. Denies hearing issues. Reports a nose bleed once last year after being hit during a soccer game. Reports no issues eating, swallowing, or pain in throat. Reports he saw the dentist last week.
Mother: Hx Breast Cancer. Seasonal Allergies. Anxiety. Maternal Grandmother: Asthma Paternal Grandfather: Died in 2009 liver Cirrhosis from etoh abuse.Father: MI age 30 from cocaine abuse. Bipolar disorder. Maternal Grandmother: None Paternal Grandfather: Substance AbuseSister: 19 Asperger’s, Anxiety, Depression. Half-Brother- 5 Cerebral Palsy Half Brother-Deceased Still Born
ROS:General: Denies fatigue, weakness, fever, chills, sweat, loss of appetite, and weight loss. HEENT: Denies any wounds, lumps, or pain. Denies vision issues. Denies hearing issues. Reports a nose bleed once last year after being hit during a soccer game. Reports no issues eating, swallowing, or pain in throat. Reports he saw the dentist last week.Neurological: Denies headaches, pain, and dizziness or head injuries. Denies changes in memory. Denies numbness and tingling.Skin: Denies any wounds, rashes or moles. Reports, “I have a birth mark on my right butt check”.Cardiovascular: Denies chest pain, palpitations, and racing. No hx noted.Peripheral Vascular: No hx noted.Respiratory: Denies SOB, cough, and pain.Gastrointestinal: Denies abdominal pain, nausea, vomiting, constipation or diarrhea. Reports not troubles eating. Reports he eats “lots of pasta for energy”.Genitourinary: Denies issues including nocturia, dribbling, incontinence, discharge, or pain upon urination. Musculoskeletal: Reports knee pain bilaterally dull and achy 3/10 presently. Denies issues, running, jumping, kicking, or bending. Reports clicking sounds at times when knee is flexed and extended. Hematologic: Denies bleeding or bruising. Reports nose bled last year after being hit in a soccer game. No other hx notedLymphatics: Denies swelling and tenderness. No Hx noted.Endocrine: Denies heat or cold intolerance, excessive thirst or urination, or tremors. No hx noted.Psychiatric: Denies depression, thought of self- harm. Reports anxiety when taking Chemistry tests.Allergies: Denies.Physical Exam: BP 120/70 adult cuff/right arm/sitting, P 72 regular, RR 18 unlabored. O2 98%, T 98.6 temporal. Weight 185. Height 5 feet 11 inches. BMI 25General: Aox4, looks stated age, pleasant, well groomed, and cooperative. Makes eye contact when speaking and answering questions. No s/s of distress.HEENT: Head symmetrical No visual deformities noted. PER/EOMI. Responds to questions with no requests to repeat. Breaths through nares no s/s of congestion, or allergies. Teeth are intact, bright white, straight, and no odor from mouth present.Neurological: AOX4, No s/s of neurological deficits. Adequate recall.Neck: No visual lesions, no enlargement, no JVD. Skin/Lymph: Intact. No wounds, lesions, scars or moles noted. Tan in complex. No signs of edema or cyanosis. No nodes observed upon palpation. Chest/Pulmonary: Chest is symmetrical. CTA AP&L. Respiration even and unlabored noted at 19. No noted SOB, RR noted at 18, SPO2 98%. No use of accessory muscles noted. Heart/Vascular: S1 and S2 noted. RRR. No murmurs, rubs, or gallops noted. Less than 3 capillary refill. All Pulses 3+. HR slightly elevated along with BP indicative of pain.Abdomen: Deferred No issues noted. Genital/Rectal: Deferred no issues noted.Musculoskeletal: Ambulates on own, full weight bearing. Mild swelling, tenderness, warmth noted in bilateral knees. Pain with palpation over the tibial tuberosity. Flinches upon flexion and extension of both knee.Diagnostic Results/Manipulation Test: Negative Lachman test. Negative Homan’s sign. Negative McMurray test. Differential Diagnoses 1. Patellofemoral Pain Syndrome 2. Meniscus tear 3. Osgood Schlatter Disease 4. Osteogenic Sarcoma
