Cardiac:
The point of maximum intensity of the cardiac impulse is in the fifth
Bones, Muscles, and Joints:
bral angle tnederness.
The bones are not tender.
Rectal:
legs.
:
There is no costoverte-
Abdomen: The abdomen is soft, nontender. Bowel sounds are normal. Hepatic
Span to percussion is 10 cm. Liver spleen, and kidneys are not palpable, and thera
are no abnormal abdominal masses or bruits.
'
Genitalia:
mw
intercostal space in the midclavicular line. Cardiac rhythm is regular. There is a
Grade [I/VI soft systolic murmur head best at the aortic area, radiating slightly
toward the Left sternal border but not toward the neck. The second heart sound
splits normally.
{
|
4
—~ 4
|
Normal male.
Examination is normal.
Extremities:
OR
The extremities are normal, with multiple healed scars over the
Skin: There is a depigmented geographic rash over the chorax and upper extremities, which is slightly scaling in places.
Neurological:
Examination is entirely within normal limits.
IMPRESSION:
1.
2.
Acute granulocytic leukemia.
History of resection of thyroid nodule, clinically euthyroid now.
4,
5.
6.
Mild cutaneous furunculosis.
Chronic left otitis media.
Partially erupted right lower third molar with periodontitis.
3.
Tinea versicolor.
PROGNOSIS: ©
on
.
|
oo
ol. oo aaa
Fifty percent chance of achieving remission of his leukemia; median survival |
about one year in other pacients with a similar disease.
James Mabry, M.D./C/10-4-72
JM:kr D-X
Rongelap (54) 09-44-40 3
,
-~3-
THE CLINICAL CENTER
NATIONAL INSTITUTES OF HEALTH
- 142 -
10-5-72
CLINICAL RECORD
.
El Hissery ond Piryslenl Exominotion ~*
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