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:

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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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‘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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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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eres

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- 141 -

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