Author: Jessica Huerta, DO, MS
Co Author #1: Patrick Leary, DO
Editor: Kristine Karlson, MD
A 19-year-old male college freshman presented for his Pre-Participation Physical Examination in baseball. Previously this athlete participated in football, wrestling and baseball without injury.
He reported no complaints or concerns except for mild asthma in cold weather and contact lens use. The patient’s speech pattern was abnormal and was consistent with a long term hearing deficit. Ultimately, the patient revealed he underwent surgery for congenital ear canal abnormality and now uses a hearing aid.
General: Well developed, well nourished, no acute distress. Height 5’8”, Weight 160lbs, HR 80bpm, BP140/88, 128/74 on repeat, Visual Acuity with contacts – Left & Right 20/15. Speech pattern consistent with long term hearing deficit.
HEENT: Pupils equal, round and reactive to light and accommodation, extraocular movement intact and without nystagmus. The face is symmetric. Tongue and palate are midline. Right hearing aid in place.
Cardiovascular: Peripheral pulses 2+ and equal, HR regular without murmur.
Gait: nonantalgic, normal arm swing, ambulates on forefoot.
Skin: no skin lesions or rashes. Short neck with low hairline.
Spine: C-spine Sidebent right Rotated right with head deviated to the right from midline, upper thoracic dextroscoliosis. Full active range of motion lumbar spine. Reduced active range of motion cervical and thoracic.
Muscular: Strength 5/5. Reflexes symmetrical.
Negative clonus, Hoffman’s and Babinski.
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