Dyspnea and Back Pain in a 24-yr-old Man

Physical Examination

  • General appearance: Well-appearing, normal body habitus, and in no distress.

  • Vital signs:
  • Temperature: 36.2° C
  • Pulse: 79 beats/min
  • Respirations: 18/min
  • BP: 122/72 mm Hg
  • Pulse oximetry: 94% on room air

  • Skin: No cyanosis, diaphoresis, rash, or other lesions.

  • HEENT: Anicteric sclerae, pupils equally round and reactive to light. Oropharynx clear.

  • Pulmonary: Normal respiratory effort. Decreased breath sounds on the right side.

  • Cardiovascular: Normal rate, regular rhythm. No murmurs, rubs, or gallops. Jugular venous pressure is not elevated. Pulses normal and symmetric in upper and lower extremities.

  • Gastrointestinal: Soft, nontender, nondistended abdomen; normal bowel sounds.

  • Genitourinary: Not assessed

  • Musculoskeletal: Chest, back, and spine nontender; no palpable crepitance. Extremities appear normal; no leg swelling, erythema, or tenderness.

  • Neurologic: Upper and lower extremities have normal, symmetric strength, sensation, and deep tendon reflexes in upper and lower extremities. Gait normal.

  • Mental status: Appropriate. Alert and oriented.