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Geoffrey P. Hawkins Hospital# 54-98-10

PHYSICAL EXAMINATION

GENERAL: The patient is a well developed, well nourished white male who appears his age of eleven and a half. He is of moderately small stature but is well tanned from being in the sun. He appears to be in no acute distress but is quite apprehensive.

HEENT: SKIN: Is warm and dry, well tanned; no jaundice, no lesions. EYES: The pupils are round, regular and equal; react to light and accommodation. No icterus seen. Conjunctivae normal. EARS: Drums pearly, hearing is good to spoken voice. NOSE: Septum straight. No lesions. MOUTH: And throat are benign. The tonsils are small and the teeth are in good repair.

NECK: Is supple. The thyroid is not enlarged. There is no remarkable lymphadenopathy. Trachea is in the midline with no tug. LUNGS: Are clear to percussion and auscultation. HEART: Regular sinus rhythm, no murmurs heard. A2 is louder than P2.

ABDOMEN: Is scaphold with no scars. Patient indicates midepigastric tenderness. Peristalsis is audible and possibly slightly hyperactive but very close to average in intensity. There is some tenderness, mainly in the right upper quadrant. Both left and right lower quadrants appear to be soft with no rebound present. Equivocal Murphy punch tenderness is present. No CVA tenderness.

GENITALIA: Testes down, no penile lesions.

RECTAL: There is stool in the ampulla. Sphincter tone is good. Patient complains of some tenderness in both vaults, but no masses found.

SKELETAL: No gross bone or joint anomalies.

NEUROLOGICAL: No motor or sensory loss found. Deep tendon reflexes active and equal. Toe signs down. Pedal pulses palpable.

IMPRESSION: Abdominal pain, etiology unproved, but probable gastroenteritis. Rule out early appendicitis.

Lc
D:9/11/2015
T: 9/11/2015
Paul R. Elsner, MD

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