renifejn
Guru
Diagnosis: JDM
Other diagnoses: none
Social History (grade, PE, activities, school days missed): Sr in HS, good grades, ful pe, badmitton, tennis, golf, missed 4 days due to pneumonia
SPECIFIC COMPLAINTS/PROBLEMS ILLNESS:
none
NEW FAMILY HISTORY:
none
REVIEW OF SYSTEMS:
SKIN: Normal
EYES: Normal
EARS: Normal
NOSE: Normal
MOUTH: Normal
RESP: Normal
CARDIO: Normal
GI: Normal
MUSCULOSKELETAL: Normal
NEURO: Normal
GU: Normal
Nighttime Urination: No
MENSES: Yes Time Between Periods 28 days
ENDOCRINE: Normal
PSYCH: Normal
LYMPHATIC: Normal
Eye Exam: Yes Date of Last Eye Exam 1/09
General appetite: good
Calcium intake in diet? Yes Servings per day? 3
Sunscreen use? Yes SPF # 45
Pain: No
Stiffness: None
Presence of Infection: No
Infectious episodes since last visit: Yes Number of episodes: 2 Location of infection(s): Pneumonia-treated with a Z-Pak
Functional Status: Normal function (able to attend school, keep up with friends)
PHYSICAL EXAM:
Blood pressure 121/77, pulse 80, resp. rate 20, height 151.2 cm, weight 40 kg.
BSA: Body surface area is 1.37 meters squared.
GENERAL APPEARANCE: Normal
SKIN: ABNORMAL: Vitiligo on back
HEAD: Normal
EYES: Normal
EARS, NOSE, THROAT, MOUTH: Normal
NECK: Normal
RESPIRATORY: Normal
CARDIOVASCULAR: Normal
ABDOMINAL: Normal
GENITOURINARY: Tanner Stage: 3
MUSCULOSKELETAL: Normal
NEUROLOGIC: Normal
PSYCHIATRIC: Normal
Skin Involvement: Absent or resolved completely
Distribution: None
Neck Flexor Weakness: No Grade: 5
Difficulty clearing scapula (abdominal weakness) No
Can do sit-up with: 3=behind head
Upper prox. muscle weakness 5 No
Lower prox. muscle weakness 5 No
Gower's sign: Unassisted
Abnormal gait No
Difficulty swallowing No
Nasal speech No
Spine Expansion: 15-22cm
Vasculitis: No
Severe Vasculitis: No
Gotrons' Papules: Absent
Calcification: Absent
Peripheral fat atrophy: Absent
Acanthosis Nigricans: Absent
Raynaud's: Absent
Loss of ROM No
Status of JDM: No Rash or Weakness
Meds: On Immunosuppressive therapy
VISIT IMPRESSION:
JDM-stable exam, no active arthritis
VISIT PLAN:
Lab evaluation today
Other diagnoses: none
Social History (grade, PE, activities, school days missed): Sr in HS, good grades, ful pe, badmitton, tennis, golf, missed 4 days due to pneumonia
SPECIFIC COMPLAINTS/PROBLEMS ILLNESS:
none
NEW FAMILY HISTORY:
none
REVIEW OF SYSTEMS:
SKIN: Normal
EYES: Normal
EARS: Normal
NOSE: Normal
MOUTH: Normal
RESP: Normal
CARDIO: Normal
GI: Normal
MUSCULOSKELETAL: Normal
NEURO: Normal
GU: Normal
Nighttime Urination: No
MENSES: Yes Time Between Periods 28 days
ENDOCRINE: Normal
PSYCH: Normal
LYMPHATIC: Normal
Eye Exam: Yes Date of Last Eye Exam 1/09
General appetite: good
Calcium intake in diet? Yes Servings per day? 3
Sunscreen use? Yes SPF # 45
Pain: No
Stiffness: None
Presence of Infection: No
Infectious episodes since last visit: Yes Number of episodes: 2 Location of infection(s): Pneumonia-treated with a Z-Pak
Functional Status: Normal function (able to attend school, keep up with friends)
PHYSICAL EXAM:
Blood pressure 121/77, pulse 80, resp. rate 20, height 151.2 cm, weight 40 kg.
BSA: Body surface area is 1.37 meters squared.
GENERAL APPEARANCE: Normal
SKIN: ABNORMAL: Vitiligo on back
HEAD: Normal
EYES: Normal
EARS, NOSE, THROAT, MOUTH: Normal
NECK: Normal
RESPIRATORY: Normal
CARDIOVASCULAR: Normal
ABDOMINAL: Normal
GENITOURINARY: Tanner Stage: 3
MUSCULOSKELETAL: Normal
NEUROLOGIC: Normal
PSYCHIATRIC: Normal
Skin Involvement: Absent or resolved completely
Distribution: None
Neck Flexor Weakness: No Grade: 5
Difficulty clearing scapula (abdominal weakness) No
Can do sit-up with: 3=behind head
Upper prox. muscle weakness 5 No
Lower prox. muscle weakness 5 No
Gower's sign: Unassisted
Abnormal gait No
Difficulty swallowing No
Nasal speech No
Spine Expansion: 15-22cm
Vasculitis: No
Severe Vasculitis: No
Gotrons' Papules: Absent
Calcification: Absent
Peripheral fat atrophy: Absent
Acanthosis Nigricans: Absent
Raynaud's: Absent
Loss of ROM No
Status of JDM: No Rash or Weakness
Meds: On Immunosuppressive therapy
VISIT IMPRESSION:
JDM-stable exam, no active arthritis
VISIT PLAN:
Lab evaluation today