SOCIAL HISTORY:
The patient was born and has lived all his life in the Marshall Islands except for
one visit to Boston, where he was hospitalized for a thyroidectomy in 1967, He graduated
from high school last year.
fluent.
He has working knowledge of English, although he is not
REVIEW OF SYSTEMS:
Head:
Anacin.
The patient gets a rare fronto-occipital headache, which is relieved by
The frequency of these headaches has not changed recently.
seizure disorder, no history of syncope. Ears ~ No complaints.
The ‘pactent does‘not wear glasses. Nose and Mouth - Negative.
He has no known
Eyes - Vision good.
2,
: Pulmonary: 4 ‘No.“chronic cough, no shortness of breath.
, oe,
.
Cardiovascular:. Negative. 2.
“Gastrointestinal::
Negative.
7 ee
sa
e
!-Skta: The patient has had multiple skin infections on the legs, often resulting
from-cuts and scratches. In addition, he has had boils on the buttocks over the last
few months and a mildly prutitic, depigmenting rash over the thorax for the last six
months../
“SET.
RE
*.Lee.
.
Endocrine:
=x
ae
Subtotal thyroidectomy 5 yrs prior to admission for multiple benign
nts .
adenomas.
On synthyroid since.
_A¥ital Signs:i,Blood pressure,110/60; pulse 90; respirations 16.
.
oa,
scalp. tenderness...Pupils are equal, round, and reactive to light and to accommodation.
me extraocular movements are intact. Visual fields are intact to confrontation test-
ing.,»7There is no-nystagmus. The fundi are normal.
The Weber test does not lateralize..
the righe tympanic: membrane is. slightly scarred and retracted; the left tympanic men-
brane-is distorted,dull, particularly in the postero-inferior quadrant, with a slight
tanexudate at thebase. The pharynx is normal. There is slight inflammetion surrounddng.the. right mandibular thirdmolar, which is partially covered by a soft tissue flap.
va
eo
-
wae cet
TDL
‘There ts‘nowvenous distention. Two’well-healed horizontal sur-
eaantertorly_over the neck.
oa
B+
~
Ko palpable thyroid tissue is present.
.
via tome
owe
" :cagtweck:” Supple
gicaltscars are
rt.
.
Pax
eeeChest: The chest" expands’“cyemitrically.“the ‘Lung fields are clear to percussion
-
bongelap (54)
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eA
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‘iGeneral Appearance: This is a well-developed, muscular, young man in no distress.
ms
Ages.
iSaag,
: ore.
“Head, Eyes, Ears, Nose and Throat: The head is symmetric. There is no bony or
a he ind se ee
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uew errr
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nwa tee ae
.
cedures
PHYS ICAL EXAMINATION:id
_
2
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THE CLINICAL
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T.NATIONAL INSTITUTES OF HEALTH
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