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Continuation of S$. F, Final Sicucary,_Noveaber_ ely,4972.
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a ze
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(Sign and date)
hydrogen bomb testing during 1954.
aday.
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Report on —
CLINICAL RECORD
social drinking.
’
Patient stated he did not drink, occasional
He was on DBI 50 milligrams tivico a day, Benenid four times
Family history was not remarkable.
and lumbosacral strain.
In 1951, he had spinal neningitis
In 195, radiation sickness, diabetes mellitus and hypo
thyroidism and gout since 1963.
adonoidoctomy in the 1950's,
Ho had an appendectomy and tonsillectory an
The raview of systems was essentially as oyscented
in tho history of present ilinc::s.
On physical examination, he was a well-dovelope
modcrataly obese’ malo in no neute distress, alort, conscious, coherent and intel-
ligent.
Blood pressure was 110/100 right arm rocunbent position, pulse 83 and
regular, respivationS 20 per minute and regular. Head, eyes, cars, nose and
throat examination revealed prominent conjumctivae, scleraug clear, pupils reactivo
to Light and accommodation,
fundi revealed Grade I to II changes and they also
had small militiplo exudates, bilateral, more on the left side.
Uvula and soft ~~
palate midline. Tongue well papulated and midline.” Neck - JVP not distended;
carotids eqial,’ no bruits; no lymph nodes palpable; thyroid barely palpable.
‘ha
chest was clear to percussion and auscultation. Heart revealed PMI imoossible to
find secondary to massive obesity. Heart rate 88 per minute. Heart sounds quite.
normal; no murmur; no gallop. Abdominal wall was fairly obese, bowel sounds pre- -
sent, non-tender, non-rigid; no hepatosplenomezgaly.
Rectal normal, boggy prostate
and a few external skin tags. Peripheral blood systems normal, peripheral vessels
palpable.
Skeletal system normal. Neurological exanination revealed left lc er
extremity small deficit of sensory and position sense on the left. Motor sys. a
intact. Cranial nerves normal. Cerebral systen normal. Gait and speech normal.
Reflexes within normal limits. Examination of the skin reveals a few mitiple
freceles and nevi over the back, over the front and around the neck.
‘he various”
investigations done while he was in the hospital showed the urinalysis - color”
yellow clear, reaction 6.0,-specific gravity 1.013; albumin, sugar, acetone nega-
tive, occasional red blood cell, rare white blood cells. “Culture and sensitivity
a3 essentially negative. Later on, the urine examination revealed 10 to 12 White
blood cells por high field. Urine culture and sensitivity revealed colony count’
moro than 15,000 colonies, prodeminantly Stroptecocci, not onterococci.
rWhito
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blood call count was 9,200, hematocrit 48%, hemoglobin 15.2, red blood colls 6.9.
Roticulocyte comt in the beginning was 5.3, later it fel. to 4.2%.
PBI was 4.2.
Uric acid - initially, it was 8.5, later on in treatment with ALlopurinol and
Beremid fell down to 5.2.
revealed sugar 3 positive.
VDL was non-reactive. Urine examination, Clinitest,
WSC stone differential showed neutrophiles 56, bands 2,
lymphocytes 37, monocytes 3, eosinophiles, platelets 204,000.
Electrolytes:
C02
24, chlorides 98, sodium 142, potassium .7, calciwn 9.7, phosphorus 3.7 and uric
acid 6.5. Cholesterol 269, urea nitrogen 13, creatinine1.0, alkaline phosphatase |
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PATIENTS IOENTIFICATION (For typed of writen aenirres dive: Nameiant, frat,
middie, grade; date; hatprial or medical facility)
REGISTER po.
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a
REPORT ON °
DOE ARCHIVES
meee ee
v
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or CONTINUATION OF
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WA Hospital, Houston, Texas rg 11-27-1970
WARD NO
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Atandard Form 407
507-104
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