Sports Physical Template

Subjective: John Doe is a 16-year-old male presenting today for a sports physical exam. Sports: Soccer, Basketball Medical History: - Prior orthopedic injury: Denies - History of concussion: Denies - History of exertional chest pain/discomfort or palpitations: Denies - History of unexplained syncope/near syncope: Denies - Excessive exertional and unexplained dyspnea/fatigue: Denies - Prior history of a heart murmur: Denies - History of high blood pressure: Denies Pertinent Family History: - Family history of premature death (sudden and unexpected, or otherwise) before age 50yrs due to heart disease: Denies - Family history of disability from heart disease in a close relative <50yrs of age: Denies - Family history of specific cardiac conditions (hypertrophic or dilated cardiomyopathy, long QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias): Denies Physical Exam: Vision: R20/20 L20/20 OU20/20 General: A&O x3, in no acute distress HEENT: PERRLA, EOMI, normal oropharynx, normal tympanic membranes Neck: No lymphadenopathy, no neck vein distension, no thyromegaly Cardiovascular: RRR no MRG with squatting or standing Respiratory: equal breath sounds bilaterally; no rales, rhonchi, or wheezes Abdomen: Soft, non-tender, non-distended, normal BS in all quadrants; no palpable hepatomegaly or splenomegaly GU: Deferred Skin: no rash, no abnormalities Musculoskeletal: - General: Symmetric upper extremities, lower extremities, trunk - Neck: full ROM in all directions; able to touch chin to chest and ears to shoulders - Back: symmetric back with no signs of spinal curvature when standing straight or bent over to touch toes - Shoulder/Arm: 5/5 strength in deltoids; ROM- normal flexion, extension, internal and external rotation - Elbow/forearm: 5/5 strength in biceps, and triceps; ROM- normal extension, flexion, supination, and pronation - Wrist/hand: 5/5 strength in wrist flexion, wrist extension, and finger interossei - Hip/thigh/knee: able to squat on heels and duck walk for at least four steps without pain, heel to buttock distance is equal on both sides and knee flexion is equal during the walk - Leg/ankle/foot: able to walk on heels and toes; symmetric calf muscles - Signs of Marfans syndrome: negative for pectus excavatum, thumb sign, and wrist sign Specific Pertinent Physical Exam Findings: - Blood Pressure: Normal BP - Cardiac auscultation: No cardiac murmur identified with dynamic cardiac auscultation - Pulse examination: Normal simultaneous palpation of radial and femoral pulses - Marfan's syndrome screening: No signs of Marfan's syndrome (as above) ASSESSMENT/PLAN: No concerns at this time. Pt cleared for all activity. Additional Notes: See scanned athletic participation form for further details regarding sports-related medical history and ROS