Sports Physical Template

Subjective

Lucas Vance is a 16-year-old male who presents for a sports physical examination today.

Sports: Cross-country running, track and field

Medical History

• Previous orthopaedic injury: R grade 1 lateral ankle sprain (14/10/2023), fully rehabbed, asymptomatic
• Previous concussion: Denies
• Exertional chest pain or discomfort, or palpitations: Denies
• Unexplained fainting or near-fainting: Denies
• Unusually marked exertional or unexplained shortness of breath or tiredness: Denies (Known Hx of mild GERD and Crohn's disease in deep clinical remission on mesalazine (mesalamine, Lialda®) 2,400 mg PO QD and omeprazole (Prilosec®) 20 mg PO QD; no active GI bleed, anemia, or fatigue)
• Previous heart murmur: Denies
• Previous high blood pressure: Denies

Pertinent Family History

• Family history of premature death from heart disease, whether sudden and unexpected or otherwise, before age 50 years: Denies
• Family history of heart-disease-related disability in a close relative younger than 50 years: Denies
• Family history of specified cardiac disorders, including hypertrophic or dilated cardiomyopathy, long QT syndrome or other ion-channel disorders, Marfan syndrome, or clinically significant arrhythmias: Denies

Physical Exam

Vision: R 20/20 L 20/20 OU 20/20

General: Alert and oriented ×3, without acute distress

HEENT: PERRLA, EOMI, normal oropharynx, and normal tympanic membranes

Neck: No lymphadenopathy, neck-vein distension, or thyromegaly

Cardiovascular: RRR without MRG on squatting or standing

Respiratory: Breath sounds equal bilaterally, with no rales, rhonchi, or wheezes

Abdomen: Soft, non-tender, and non-distended, with normal bowel sounds in every quadrant and no palpable hepatomegaly or splenomegaly

GU: Deferred

Skin: No rash or abnormality

Musculoskeletal

• General: Upper limbs, lower limbs, and trunk are symmetric
• Neck: Full movement in every direction; the chin can reach the chest and each ear can reach the corresponding shoulder
• Back: Back is symmetric, with no apparent spinal curvature while standing erect or bending forward to touch the toes
• Shoulder/Arm: Deltoid power is 5/5; flexion, extension, internal rotation, and external rotation have normal ROM
• Elbow/forearm: Biceps and triceps power is 5/5; extension, flexion, supination, and pronation have normal ROM
• Wrist/hand: Wrist flexion, wrist extension, and finger-interossei strength are 5/5
• Hip/thigh/knee: Can squat on the heels and duck-walk at least four steps pain-free; heel-to-buttock distance is equal bilaterally, as is knee flexion during the walk
• Leg/ankle/foot: Can walk on the heels and toes; calf muscles are symmetric
• Signs of Marfans syndrome: No pectus excavatum, thumb sign, or wrist sign

Specific Pertinent Physical Exam Findings

• Blood Pressure: 112/68 mmHg
• Cardiac auscultation: Dynamic cardiac auscultation reveals no murmur
• Pulse examination: Radial and femoral pulses are palpated simultaneously and are normal
• Marfan's syndrome screening: No features of Marfan's syndrome, as described above

ASSESSMENT/PLAN

No current concerns. Cleared for all activity. Continue current GI maintenance regimen (mesalazine 2,400 mg PO QD, omeprazole 20 mg PO QD) and maintain adequate hydration during training.

Additional Notes

Refer to the scanned athletic participation form for additional details about sports-related medical history and ROS.