Vitals: BP 123/78; HR 78; RR 16; SpO2 97%; Temp 36.6°C
General: Not in acute distress, normal appearance, and he is well-developed. He is not ill-appearing, toxic-appearing, or diaphoretic.
HEENT: Normocephalic, atraumatic, pupils are equal, round, and reactive to light, legally blind
Neck: Normal range of motion, neck supple, no neck rigidity or muscular tenderness, no tracheal deviation
Cardiac: Regular rate and rhythm, normal heart sounds, no murmur, no friction rub, no gallop
Chest wall/Pulmonary: Pulmonary effort normal, no respiratory distress, normal breath sounds, no stridor, no wheezing, rhonchi, or rales, and no tenderness to the chest wall
Abdominal: Soft, no mass, no tenderness, no guarding or rebound
- Left knee swelling, left knee tenderness, inability to extend his left lower extremity
- Tender hypertonic quadriceps muscle with contracture in the distal thigh, and no tenderness over the patella, no tenderness to tibial tuberosity or patellar tendon.
- No bony tenderness to his tibial plateau, medial, or lateral aspects of his knee
- Neurovascularly intact distally
Skin: Warm, dry, and capillary refill is less than 2 seconds.
Neurological: No focal deficit present.