Wisdom teeth extracted at age 15 without complications. He has had no difficulty chewing or swallowing. Neck: No pain, injury, or history of disc disease or compression Breasts: No reports of any breast changes. No history of lesions, masses, or rashes. Respiratory: Denies dyspnea, cough, shortness of breath. No history of asthma. . Cardiovascular/Peripheral Vascular: No history of murmur or chest palpitations. No edema or claudication. Denies chest pain. No history of arrhythmias. Gastrointestinal: Denies nausea or vomiting. Patient reports no abdominal pain, diarrhea, or constipation. Last bowel movement was this morning. Denies rectal pain or bleeding. Denies changes in bowel habits. Denies history of dyspepsia. Genitourinary: Denies changes in urinary pattern. No incontinence, no history of STDs or HPV, patient is heterosexual and not sexually active. Denies hematuria. Denies urgency, frequency, and dysuria. Musculoskeletal: No limitation in range of motion for all limbs though patient reports difficulty moving knees after excessive strain from sports. No history of trauma or fractures. Patient reports dull pain in both knees. Patient states occasional swelling in knee joints after participating in sports. Patient reports clicking in one knee and sometimes both. Patient states that the pain is worse after participating in the long jump or running longer distances. Patient denies history or presence of misalignment of either knee. Psychiatric: Denies suicidal or homicidal history. No mental health history. Denies anxiety and depression. Neurological: No dizziness. No problems with coordination. Denies falls or seizures. Denies numbness or tingling. Denies changes in memory or thinking patterns. Skin: No history of skin cancer. Denies any new rashes or sores. Denies itching or swelling. Hematologic: No bleeding disorders or history of blood transfusion. Denies excessive bruising.
Endocrine: Patient reports no endocrine symptoms. Denies polyuria, polydipsia. Patient denies no intolerance to heat or cold. Allergic/Immunologic: Denies environmental, food, or drug allergies. No known immune deficiencies. OBJECTIVE DATA: Physical Exam: Vital signs: B/P 118/76; P 76 and regular; T 98.6; RR 18; O2 100% on room air; Wt: 120 lbs.; Ht: 5’8”; BMI 19.2 General: MC is a well-developed, well-nourished Caucasian teenage male who appears to be in no apparent distress. HEENT: Head normocephalic, atraumatic. PEARL bilaterally. TMs intact bilaterally without erythema or effusion. Bony landmarks well visualized. Nares patent bilaterally. No polyps. Nasal mucosa pink and moist; no rhinorrhea. Oropharynx without tonsillar enlargement, erythema, or exudates. Buccal mucosa moist without lesions. Natural dentition, teeth stable. No gingivitis.
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- Summer '15
- History, patient denies, dull pain