History Physical Report Sample:

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History And Physical

RE:   David Jones
DATE 12/01/10
MR:  240804
DOB: 12/01/65

HISTORY OF PRESENT ILLNESS:  This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month.  The patient also reports a 15-pound weight loss.  He denies fever, chills, and sweats.  He denies cough and diarrhea.  He has mild anorexia.  Past Medical History:  Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis.  He had a recent PPD which was negative in August 1994.

MEDICATIONS:  Advil and Ibuprofen.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:  He occasionally drinks.  He is a nonsmoker.  The patient participated in homosexual activity in Haiti during 1982, which he described as "very active." He denies intravenous drug use.  The patient is currently employed.

FAMILY HISTORY:  Unremarkable.

PHYSICAL EXAMINATION:
General:  This is a thin, black cachectic man speaking in full sentences with oxygen.
Vital Signs:  Blood pressure 96/56, heart rate 120. No change with orthostatics. Temperature 101.6 degrees Fahrenheit. Respirations 30.
HEENT:  Funduscopic examination normal. He has oral thrush.
Lymph:  He has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.
Neck:  No goiter, no jugular venous distention.
Chest:  Bilateral basilar crackles, and egophony at the right and left middle lung fields.
Heart:  Regular rate and rhythm, no murmur, rub or gallop.
Abdomen:  Soft and nontender.
Genitourinary:  Normal.
Rectal:  Unremarkable.
Skin:  The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender.  He has very pale palms.


LABORATORY:  Sodium 133, potassium 5.3, BUN 29, creatinine 1.8, hemoglobin 14, white count 7100, platelet count 515, total protein 10, albumin 3.1, AST 131, ALT 31, urinalysis shows 1+ protein, trace blood, total bilirubin 2.4, and direct bilirubin 0.1.

X-RAYS:  Electrocardiogram shows normal sinus rhythm. Chest x-ray shows bilateral alveolar and interstitial infiltrates.

IMPRESSION:
1.   Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carinii pneumonia and tuberculosis.
2.   Thrush.

3.   Elevated unconjugated bilirubin.
4.   Hepatitis.

5.   Elevated globulin fraction.
6.   Renal insufficiency.

7.   Subcutaneous nodules.
8.   Risky sexual behavior in 1982 in Haiti.

PLAN:
1.   Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis.
2.   Begin intravenous Bactrim and erythromycin.

3.   Begin prednisone.
4.   Oxygen.

5.   Nystatin swish and swallow.
6.   Dermatologic biopsy of lesions.

7.   Check HIV and RPR.
8.   Administer Pneumovax, tetanus shot, and Heptavax if indicated.