MN552M4 Musculoskeletal System with Head to Toe Assessment
Patient: R.S
Age: 15
Gender: Male
Ethnicity: Caucasian
Reliability of information: The patient appears cooperative and reliable in providing information.
Subjective
CC: R.S a 15-year-old male student visiting the clinic for a routine physical examination before embarking on a camping trip with his Scout troop.
HPI: R.S reports feeling well without any current symptoms. He denies any recent illnesses, injuries, or changes in his health status. He states that he is excited about his upcoming trip and wants to ensure he is in good health for the adventure.
Objective:
General Appearance: R.S appears well nourihed and in no acute distress. He is alert, oriented, and cooperative.
Vital Signs:
- Blood Pressure: 110/70 mmHg
- Heart Rate: 80 bpm
- Respiratory Rate: 14 breaths per minute
- Temperature: 98.4°F (36.9°C)
- Oxygen Saturation: 97% on room air
Head: Proportional and without any signs of injury.
Hair: Normal in quantity, distribution, and texture. No hair loss pattern or dandruff observed.
Scalp: Appears normal with no scaliness, bumps, moles, or lesions. Skull: Normal size and shape for his age, without deformities or tenderness.
Face: Symmetrical, no involuntary movements, swelling, or masses.
Skin: Normal color, pigmentation, and texture for his ethnicity. Soft texture, normal hair distribution, and no visible lesions.
Eyes: Pupils equal, round, and reactive to light. Pupil size changes appropriately. No signs of hemorrhage or discharge. Normal vision test.
Eyebrows: Even distribution, no dryness.
Eyelids: Symmetrical, no swelling, color matches the rest of the skin, no lesions, and full lahes.
Lacrimal: No swelling or dryness.
Conjunctiva: Pink, and sclera is white.
Cornea and lens: Clear.
Iris: Normal, no signs of trauma.
EOM: Normal movements, no nystagmus.
Ears: Clear hearing, denies ear pain, ringing, or vertigo. No wax or discharge.
External ear: No abnormalities.
Ear canal: Clear, eardrum visible, no foreign bodies.
Nose: Midline septum, normal mucosa, no redness, swelling, or discharge. No deformities, normal breathing.
Mouth and Throat
Lips: Normal color, no dryness, lumps, or ulcers.
Oral Mucosa: Pink, no ulcers or white patches.
Gums and Teeth: Pink, no swelling or ulcers, no missing or discolored teeth.
Roof of the mouth: Normal color and structure.
Tongue and floor of mouth: Symmetrical, no lesions.
Throat: Pink mucosa, no exudates, denies pain or swallowing issues.
Neck: Midline trachea, supple, no tenderness in lymph nodes.
Thorax: Normal chest movement, no masses or tenderness. Normal respiratory rate and sounds.
Cardiovascular: Normal pulses, no bruits, normal JVP. Normal heart sounds, no murmurs or edema.
Abdomen: Normal contour, skin intact, flat abdomen, normal bowel sounds. No tenderness or masses. Liver and spleen non-palpable. No CVA tenderness.
Neuro: Oriented x4, intact memory and cranial nerves. Normal motor strength, coordination, gait, sensation, and reflexes.
