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Date of Exam: 06/22/2010
Patient Name: Jonathan Smith
Medical Record # 06500
CC: “Feeling Badly” “Fatigue”
This patient is a 72 year-old white male who states that he
started “feeling bad” he complains of generalized fatigue .
He also states he is having pain which is progressing.
He is also complaining of a shortness of breath and slight cough and has had night sweats,
which he relates to seasonal allergies. He has stayed in for the past 3 days taking Nyquil
and over-the-counter Claritin. He states he is getting worse and comes in for a checkup.
He has a history of a total joint replacement .
He did well with no post-op complications and was pleased with the outcome and the function
it offered. He even missed his weekly lunch date with his friend at River Crossing Assisted
Living Center yesterday. John is retired from the postal service . He worked in his garden last week .
BPH, Diabetes, GERD, Mild Hypertension,history of MRSA
Appendectomy when he was a teenager, TURP 12 years ago, TKA 5 year ago.
ENMT: Sinusitis, slight hearing loss , M&T normal
Respiratory: c/o nagging cough
GI: GERD, controlled with meds
GU: BPH, TURP
Integument: Skin lesions
Psychiatric: Normal, age appropriate
Constitutional: Hgt. 5’9”, Wt. 230 Lbs, BMI 34 Temp. 101.2,
Resp. 24, BP. 142/92, Pulse 82
WD obese pleasant male well known to me, he is concerned today because he says he feels badly and
states he “is just not his normal self.”
ENMT: Normal other than nasal inflammation, dentures
Respiratory: Exhibits shortness of breath
Gastrointestinal: Normal bowel sound x4, No tenderness
Left Knee: Walks with slight limp.
Right Knee: Normal
Skin: No rashes or abrasions. Well healed incision from previous surgery
Neurological: Sensation is normal. DTRs are normal.
Cardiovascular: Popliteal is diminished, pedal pulse is normal.
Lymphatic: Mild lymphedma to groin, no tenderness is noted.
Other: No long bone deformities are noted.
Inspection and ROM of the extremities
are normal on exam.
Administer insulin per sliding scale.
Rapid influenza test : negative
X-Ray: Rx given for X-rays
RX: For tonight only increase Glucophage to two tablets. (1000 Mg.)
He does have a prosthetic joint. There is slight enlargement of the spleen. No history of a heart
murmur. His PMH, indicated he had skin lesions about 18 months ago.
we discussed the possibility of a systemic
I recommended his daughter pick him up, stay with him tonight and come with him tomorrow.
Type II DM, Elevated Glucose, 250.02
Painful knee, status post TKA 719.46, V43.65
SOB, Abnormal chest sounds, Cough, 786.05, 786.7, 786.2
William Banister, M.D.