Abkhazia Institute for Social and Economic Research

A 16 year old male E. presents on 06/09/06 to his primary care physician with the chief complaint of constant nonspecific pain and filling of weakness in both thighs and shoulders for the past 2 weeks. He had been in his usual state of good health until 20 days ago when he had a sore throat and fever. His sore throat and fever resolved. He was not seen by a physician at that time. Over the past 2 weeks shoulders and thighs pain has been noted, but he attributed it to excessive exercising, including push ups, moderate weight lifting and school PI activity. There is no nausea or vomiting.

His urine is clear and he has been voiding as much as usual. There is no urinary frequency, urgency, dysuria or foul smell to the urine. His appetite has been usual and he is still drinking fluids well. He is also complaining of some back pain in the flank area that he describes as a dull pain that comes and goes and does not seem to be related to activity. His energy level is down and he has not felt up to going to school for the past 2 weeks, but was pushing himself to go, to avoid absences. He is also complaining of a dull generalized headache that has not been relieved with Tylenol or Advil. Those medications helped a little in reliving of “thighs and shoulders” pain.
Review of systems is negative for recent skin infection, skin rash, cough, rhinorrhea, seizure activity, fever, arthralgia or weight loss. His past medical history, family history and social history are unremarkable.
Exam: VS T 37, P 100, RR 20, BP 160/110 (RA) 150/96 (LA), oxygen saturation 100% in RA. Height 5.9 and weight 145 lbs. He is tired appearing but in no acute distress. Pupils are equal and reactive. Optic disc margins are sharp. Sclera are white and conjunctiva are clear. No periorbital edema is noted. TMs are normal. Throat, oral mucosa and nose are normal. His neck is supple without lymphadenopathy. Heart is regular without murmurs. Lungs are clear. Abdomen is diffusely tender (mild), without guarding or rebound. Bowel sounds are normal. No organomegaly is noted. Mild CVA tenderness is present.