Cardiac: The point of maximm intensity
intercostal space in the midclavicular line.
Grade II/VI soft systolic murmur head best at
toward the left sternal border but not toward
splits normally.
Bones, Muscles, and Joints:
bral angle tnederness.

of the cardiac impulse is in the fifth
Cardiac rhythm is regular. There is a
the aortic area, radiating slightly
the neck. The second heart sound

The bones are not tender.

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 there
are no abnormal abdominal masses or bruits.
Genitalia:
Rectal:
legs.

Normal male.

Examination is normal.

Extremities:

The extremities are normal, with multiple healed scars over the

Skin: There is a depigmented geographic rash over the thorax and upper extremities, which is slightly scaling in places.

Neurological:

Examination is entirely within normal limits.

IMPRESSION:
1,
2.
3.
4.

Acute granulocytic leukemia.
History of resection of thyroid nodule, clinically euthyroid now.
Tinea versicolor.
Mild cutaneous furunculosis.

6.

Partially erupted right lower third molar with periodontitis.

5.

Chronic left otitis media.

PROGNOSIS:

Fifty percent chance of achieving remission of his leukemia; median survival

about one year in other patients with a similar disease.

James Mabry, M.D./C/10-4-72

JM:kr D-X

10-5-72
CLINICAL RECORD
Th Hisery end Physica! Examination

Rongelap (54) 09-44-40 3
-3-

O summery
Consultation

.

O rottewup
OC Cantiwatton

THE CLINICAL CENTER
NATIONAL INSTITUTES OF HEALTH

- 142 -

WIN.99F (Rev. 5-71)

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