Based on the following case study scenario, use this document to answer the questions below, then upload the document for the faculty.
Case study scenario
A 12-year-old male presents to the pediatric clinic for a well-child exam. He has no chronic illness and no significant past medical history. He is entering the seventh grade and is doing well in school and active in sports. Below is the physical exam for this patient; please identify any abnormal findings on his physical assessment:
General survey: Patient is awake, alert, and oriented to person, place, and time. Skin is pink, warm, and dry. Facial features are symmetric. He appears in no distress. He appears healthy and looks his stated age. He is sitting upright in a chair and appears comfortable and happy. No physical deformities noted. He has a steady gait. Patient maintains eye contact with appropriate facial expressions. Speech is clear and fluent. He is dressed appropriately for cold weather and appears well-groomed.
Skin, hair, and nails: Skin tone is even with no abnormal pigmentation. He has freckles on his face. Several nevi noted on back, one to two mm in size with regular distribution and borders. No rash or bruising noted. Skin warm and dry and normal texture. No edema. He has good skin turgor. He has no tatoos or lesions. His hair is dark with some graying. No hair loss noted. Nails appear clean and smooth with no abnormalities. Nail beds are pink. Capillary refill is less than two seconds.
Head: Normocephalic. No lumps, rashes, or lesions noted. No tenderness to palpation. Equal facial symmetry.
Neck: Trachea appears midline. Full ROM. Has 2/10 pain in the left side of his neck with movement. No enlarged lymph nodes. Left side of neck is slightly tender to palpation. Thyroid gland is not enlarged. Carotid artery is 2+ bilaterally. No bruit heard on aucultation. No JVD noted.
Ears: Appear normal in size and are equal bilaterally. No lumps, lesions, or tenderness. External ear canal without redness, swelling, lesions, or discharge. Tympanic membranes appear pearly gray in color bilat. No perforation noted.
Eyes: Snellen eye chart- 20/40- OD, 20/40- OS, 20/40- OU. Does not wear corrective lenses. Confrontation test normal. Corneal light reflex equal bilat. Parallel eye movement noted during diagnostic positions test. No nystagmus. No lid lag. Eyes appear symmetrical. Eyebrows move symetrically. No scaling noted. No evidence of ptosis. No swelling, rash, or lesions noted. Horizontal palpabral fissures and eyelashes are present and full. Conjunctiva is clear. Sclera appears white. PERRLA. Red reflex noted with opthalmascope bilat.
Nose and Sinuses: Nose appears symmetric and normal in size for patient's face. No deformity or skin lesions noted. Freckles present on nose. Nares are patent with no swelling, redness, or drainage. No septal deviation. No tenderness upon palpation of sinuses.
Mouth: Lips are pink and moist with no cracking or sores. Mucous membranes are pink and moist. Teeth appear white with some yellow stains. No evidence of decay noted. Teeth appear well-maintained. No malocclusion. Tongue is pink and moist with no lesions. It protrudes midline and is normal in size. Patient is able to curl his tongue and move it right to left. Buccal mucosa pink and moist without lesions or white patches.
Throat: Uvula appears midline without lesions. Tonsils present, +4. Gag reflex present.
Thorax and lungs: Chest expansion symmetric. RR 16 and nonlabored. No palpable crepitus. Tactile fremitus is equal biaterally. Lung fields are resonant upon percussion. Lung CTA. Arterial oxygen saturation obtained by pulse oximeter on finger is 99 percent.
Breasts: No lumps or swelling noted. Axillary lymph nodes not palpable.
Heart: Apical impulse not visible. No presence of heave or lift. Unable to palpate apical impulse. No abnormal pulsations felt. HR 52 and regular upon auscultation. S1, S2 present and normal. S3 and S4 not heard. No murmur.
Peripheral Vascular System: Capillary refill less than two seconds. Radial pulses 2+ bilaterally. No palpable epitrochlear lymph nodes. No swelling noted in bilateral LE. Skin is pink, warm, and dry. Hair present on bilat LE. No presence of varicose veins. Femoral, politeal, dorsalis pedis, and posterior tibial pulses 2+ bilaterally.
Abdomen: Symmetric bilaterally with no visible mass or bulge. Vertical scar present starting above and around umbilicus and proceeds down four inches. Umbilicus is inverted with no signs of hernia. Abdomen soft, nondistended, nontender. No palpable masses. Liver is not enlarged. No splenomegaly. Tympany noted over abdomen with dullness noted over the liver in the right upper quadrant. No costovertebral angle tenderness. Bowel sounds present and active in all four quadrants. No bruits heard over abdomen. Negative Blumberg sign. Negative Murphy's sign.
Anus/rectum/prostate: Anus appears moist without the presence of fissures or hemorrhoids. No lesions, redness, or swelling noted. Anal canal feels smooth and even upon palpation. Sphincter tightens around finger. No swelling, tenderness, or masses noted. Rectal wall feels smooth with no masses.
Genitalia: No rash, lesions, redness, swelling, or discharge noted on the penis. No scrotal edema. Testicals present and symmetrical. No swelling or tenderness.
Musculoskeletal: No redness, tenderness, swelling, masses, or deformity over joints. Patient is able to move all extremities without difficulty. No pain or crepitation upon movement. Good muscle strength.
Neurologic: Patient is awake, alert, and oriented to person, place, and time. Facial symmetry equal. No facial droop or ptsosis. PERRLA. Tongue midline. Equal smile. All cranial nerves intact. Equal strength in bilateral extremities. No involuntary movements. Steady gait. Patient able to perform finger-to-finger test without difficulty. Negative Romberg test. Normal sensation. No parasthesias. Sterognosis- Patient able to identify key with his eyes closed. 2+ biceps, triceps, brachioradialis, quadriceps, and achilles reflex. No clonus. Normal abdominal reflex. Normal plantar reflex. No Babinski sign.
- Now identify the vaccines needed at this visit. This patient is currently up to date and has received all recommended vaccines on time at previous well visits.
- List all abnormal assessment findings on the patient's physical exam.
- List pertinent and specific patient teaching points based on the recommended vaccines to be given at the well-child visit (minimum of seven) and develop a patient teaching handout for the parents. (Be sure to include the patient teaching handout for parents in the upload.)