A 19 year old Military Recruit Douglas A. Stahura 2/17/2001

Case Presentation You are the Military physician sent to Helena, MT to screen enlistees for military service. You are the Military physician sent to Helena, MT to screen enlistees for military service.

Joe Johnson JJ, 19 y/o WM presents for enlistment in the U.S. Marine Corp (ooh-rah) with comprehensive History and Review of Systems forms completed. JJ, 19 y/o WM presents for enlistment in the U.S. Marine Corp (ooh-rah) with comprehensive History and Review of Systems forms completed. He offers no complaints. He offers no complaints. Never hospitalized. Never hospitalized. No medications. No medications. No allergies to medications. No allergies to medications.

Joe Johnson “Usual” childhood illnesses. “Usual” childhood illnesses. “Doc, I’m healthy as a horse.” “Doc, I’m healthy as a horse.” Social: Tobacco – 1 ppd x 3 years. Social: Tobacco – 1 ppd x 3 years.  Denies EtOH, illicit/IV drug use.  HS graduate  Played football, baseball

Joe Johnson What review of systems do you want to ask? What review of systems do you want to ask?

Joe Johnson Skin – rash,hives urticaria Skin – rash,hives urticaria CV – chest pain, palpitations, dyspnea on exertion, peripheral edema CV – chest pain, palpitations, dyspnea on exertion, peripheral edema Resp – cough, wheeze, shortness of breath Resp – cough, wheeze, shortness of breath MS – injury, arthralgias, myalgias MS – injury, arthralgias, myalgias

Joe Johnson What two systems would you concentrate on during physical exam? What two systems would you concentrate on during physical exam?

Joe Johnson Vitals: Vitals:  BP-145/40, HR-72, RR-12, T  Wt-170, H-5’10” HEENT-unremarkable HEENT-unremarkable Neck-no bruit, thyromegaly; supple. Neck-no bruit, thyromegaly; supple. Skin-warm/dry; no rash Skin-warm/dry; no rash MS-no deformities, no scoliosis, extremities have full range of motion MS-no deformities, no scoliosis, extremities have full range of motion

Joe Johnson Heart: Heart:  Chest wall-no deformities  Auscultation-S1,S2 with holosystolic murmur, faint diastolic  Palpation-PMI 5 th ICS Left midclavicular line Lungs: CTA B/L, no wheezes Lungs: CTA B/L, no wheezes

Joe Johnson Abd-flat, soft, NT, no bruits, active bowel sounds Abd-flat, soft, NT, no bruits, active bowel sounds Pulses-carotid/radial/femoral/dorsalis pedis- +2/4 B/L, no bruits Pulses-carotid/radial/femoral/dorsalis pedis- +2/4 B/L, no bruits Extremities-no edema/clubbing/cyanosis Extremities-no edema/clubbing/cyanosis

Joe Johnson What other physical exam modalities can you use? What other physical exam modalities can you use? Should you be looking for something more? Should you be looking for something more? What are the significant findings? What are the significant findings? What lab testing/imaging is warranted? What lab testing/imaging is warranted?

Joe Johnson CBC CBC  RBC 5.4 x /L ( )  HGB 16 g/dl (14-18)  HCT 47% (42-52)  WBC 7.4 x 10 9 /L ( ) BMP BMP  Na , K , Cl , HCO  BUN-14, Creat-0.8, Glu-80

Joe Johnson What is your Differential list? What is your Differential list? What conditions are associated with the diagnosis? What conditions are associated with the diagnosis?

Joe Johnson What more testing can or should be done? What more testing can or should be done?