Internist, Dr. OO. Physical Exam
Interval History: He has been walking further, 5 to 5.5 miles per day. He is still working only 1.5 to 2 hours per day. There is no improvement in his ability or stamina for any longer work hours. After this length of time, he has reached his limit. A rest does not help bring back his strength for the rest of the day. He can rest an hour and then feel strong again. His ability to deal with quick change or risk is much less. The ability to deal with possible adverse consequences of a risk are reduced, and he has increased frustrations.
System Review:
Head: No headaches, dizziness or fainting spells.
Eyes: No blurring, scotoma or diplopia. He has new glasses provided by Dr. --. His astigmatism seems to be less, his myopia slightly increased.
Ears: Negative.
Nose: Negative, although years ago he states he had dust, mold, ragweed and feather allergies. Took shots which he has not needed out here. He states he has no trouble with these when we get clean ocean air, but a breeze from --- and he is much worse.
Mouth: Negative. His teeth are good. He saw his dentist yesterday.
Neck: Occasional stiffness. No pain.
Cardiorespiratory: Shortness of breath with physical acts is non-existent. He does have some shortness of breath when emotionally disturbed. No swelling of the ankles, chills, fever, chronic cough.
Gastrointestinal: His appetite is good. No particular food dyscrasias. No abdominal pain or out of the ordinary gassy eruptions. He does have trouble if he eats mustard or gets into too much garlic. Bowels are regular. Depends on the exercise.
Genitourinary: No nocturia, frequency, dysuria, gross hematuria, urgency, hesitancy or dribbling. His sex life is normal. Joints negative.
Endocrine: Tolerance to heat is zero. No increased thirst. No increased perspiration. Medication (Parnate) seems to cause some retention of water. He takes 25 mg q.a.m., 10 mg at noon, and by 8 p.m. he starts to urinate increased amounts of urine.
Physical Examination
Physical examination reveals that he is well-developed, well-nourished, no apparent acute distress. He is alert and cooperative, with many, many questions which I can not answer. His weight is 216 with shoes and trousers compared with 196 without.
Head: Hair dark brown. Scalp clean. No scars or exostoses.
Eyes: Conjunctiva and sclerae clear. Bilateral arcus senilus. Pupils equal and regular. Dilated to 0.3 cm. React to light and accommodation. EOM normal. Fundi benign.
Ears: Negative
Nose: Negative.
Mouth: Teeth in good repair. Tongue normally papillated and protrudes in the midline. Pharynx negative.
Neck: Supple. The trachea is in the midline. Thyroid gland normally palpable. The neck veins are flat. There are no bruits.
Chest: Symmetrical. Lungs clear to percussion and auscultation.
Heart: The area of cardiac diameter is not increased. The apex is 7 cm to the left of the midsternal line and the fifth interspace. The right heart border is beneath the sternum Sinus tachycardia. Rate: 104. No murmur, rub or gallop.
Abdomen: Soft. No masses, tenderness or rigidity. Liver, spleen,, kidneys not palpated.
Genitalia: Normal male. Absent hernae.
Rectal: Normal sphincter tone. The rectum is clear. Prostate is not enlarged.
Extremities: Symmetrical. Heavily clothed with good muscle tissue of good tone, and no cyanosis, clubbing or edema.
Reflexes: Physiological, toe signs down.
Back: No CVA tenderness. Normal lumbar lordoctic curve.
Chest X-Ray
The lung fields are clear. The heart and mediastinal outline are within normal limits. The bony thorax is within normal limits for the patient's age. Impression: Normal Chest.
EKG
Sinus Rhythm Rate: 66 PR: 0.14 QRS: 0.08 Axis: +60
P Waves: normal. QRS complexes: normal. ST-T waves: normal.
Conclusion: Normal EKG
Medication: Parnate: 25 mg/day.
Metrics: BP 122/80, Pulse: 104, Weight: 216 w/street clothes, 196 with out.
Lab test results:
CBC
SED Rate, ESR Westergren
SMA 17 Panel
Urinalysis
Thyroid Panel