Assignment: Edema or Cyanosis
Personal/Social: Alexander is a sophomore He plays on the basketball, baseball, soccer, football, track and wrestling team. He also loves to swim but states they do not have a team at the school. Alex states although he loves sports he wants to become a “sports doctor” and be a sports coach in his part time. Alex is proud of his 4.2 GPA and plans to graduate 1 year early and start college. He lives with his mother, adoptive father, maternal grandmother, and older sister. Alex says he has a half-brother that is 5 that leaves in Tennessee with his biological father. He states his biological father had a baby boy that died at birth a few years ago. He reports seeing his biological father a few times in the last few years. He states he has a girlfriend is named Heather, is also a sophomore and that she is a cheerleader and also plays soccer. He reports that he and Heather are not sexual active but if they become active they will use condoms. Alex is excited to get his license soon. He reports he wears his sit belt in the car and wears all protective sport gear. Denies tobacco use, drinking, illicit drug use. Reports he tried Marijuana x1 and a beer in 2018 at a party.
Immunization History: All immunization up to date per mother. Received flu vaccine 10/2018. Verified through Florida Immunization Registry.
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.
Assignment: Edema or Cyanosis
in.Abdomen: Deferred No issues noted. Genital/Rectal: Deferred no issues noted.Musculoskeleta
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:
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