A 19 year old Military Recruit

Douglas A. StahuraDouglas A. Stahura

2/17/20012/17/2001

Case Presentation

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

Joe Johnson

JJ, 19 y/o WM presents for enlistment in the JJ, 19 y/o WM presents for enlistment in the U.S. Marine Corp (ooh-rah) with U.S. Marine Corp (ooh-rah) with comprehensive History and Review of comprehensive History and Review of Systems forms completed.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.Denies EtOH, illicit/IV drug use. HS graduateHS graduate Played football, baseballPlayed football, baseball

Joe Johnson

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

Joe Johnson

Skin – rash,hives urticariaSkin – rash,hives urticaria CV – chest pain, palpitations, dyspnea on CV – chest pain, palpitations, dyspnea on

exertion, peripheral edemaexertion, peripheral edema Resp – cough, wheeze, shortness of breathResp – cough, wheeze, shortness of breath MS – injury, arthralgias, myalgiasMS – injury, arthralgias, myalgias

Joe Johnson

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

Joe Johnson

Vitals:Vitals: BP-145/40, HR-72, RR-12, T-98.6.BP-145/40, HR-72, RR-12, T-98.6. Wt-170, H-5’10”Wt-170, H-5’10”

HEENT-unremarkableHEENT-unremarkable Neck-no bruit, thyromegaly; supple.Neck-no bruit, thyromegaly; supple. Skin-warm/dry; no rashSkin-warm/dry; no rash MS-no deformities, no scoliosis, extremities have MS-no deformities, no scoliosis, extremities have

full range of motionfull range of motion

Joe Johnson

Heart:Heart: Chest wall-no deformitiesChest wall-no deformities Auscultation-S1,S2 with holosystolic Auscultation-S1,S2 with holosystolic

murmur, faint diastolicmurmur, faint diastolic Palpation-PMI 5Palpation-PMI 5thth ICS Left midclavicular ICS Left midclavicular

lineline Lungs: CTA B/L, no wheezesLungs: CTA B/L, no wheezes

Joe Johnson

Abd-flat, soft, NT, no bruits, active bowel Abd-flat, soft, NT, no bruits, active bowel soundssounds

Pulses-carotid/radial/femoral/dorsalis pedis-Pulses-carotid/radial/femoral/dorsalis pedis-+2/4 B/L, no bruits+2/4 B/L, no bruits

Extremities-no edema/clubbing/cyanosisExtremities-no edema/clubbing/cyanosis

Joe Johnson

What other physical exam modalities can What other physical exam modalities can you use?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

CBCCBC RBC 5.4 x 10RBC 5.4 x 101212/L (4.5-6.3)/L (4.5-6.3) HGB 16 g/dl (14-18)HGB 16 g/dl (14-18) HCT 47% (42-52)HCT 47% (42-52) WBC 7.4 x 10WBC 7.4 x 1099/L (4.5-11.0)/L (4.5-11.0)

BMPBMP NaNa++-138, K-138, K++-4.0, Cl-4.0, Cl---102, HCO-102, HCO33

- --24-24 BUN-14, Creat-0.8, Glu-80BUN-14, Creat-0.8, Glu-80

Joe Johnson

What is your Differential list?What is your Differential list? What conditions are associated with the What conditions are associated with the

diagnosis?diagnosis?

Joe Johnson

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