Date of Exam: 06/22/2010
Patient Name: Jonathan P. Smith
Date of Birth: 3/24/1940
Medical Record # 06500
CC: "Feeling Badly" "Fatigue"
This patient is a 72 year-old white male who states that 4
days ago he
started "feeling bad" he complains of generalized fatigueand
flu like symptoms.
He also states he is having pain in his
left knee which is progressing.
He does not recall an injury that would
cause the pain.
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 replacementin
the left knee five years ago.
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, and
is widowed, and in generally good health for his age. He worked in his garden last weekbending
BPH, Type II Diabetes, GERD, Mild Hypertension,history of MRSA
Appendectomy when he was a teenager, TURP 12 years ago, TKA 5 year ago.
Reviewed with the patient and no indication the presenting
problems have a hereditary link.
Eyes: Glasses, last eye exam 2007
ENMT: Sinusitis, slight hearing lossin left ear, 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
Normal Positive for murmur
Respiratory: Exhibits shortness of breath, coughs with deep inspiration, crackles
and rales to bilateral lower lobes.
Gastrointestinal: Normal bowel sound x4, No tenderness,
slight enlargement of spleen
Left Knee: Walks with slight limp. Pain with palpation and ROM, No joint
instability, there is swelling and erythema noted, and is warm to touch.
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 bilateral upper and lower extremities
are normal on exam.
Administer 5 units regular insulin per sliding scale.
Rapid influenza test performed in the office: negative
X-Ray: Rx given for X-rays of AP and Lateral Chest with a stat reading. Left knee for routine 4 views
LABS: Glucose, CBC, CMP, UA with C&S, and sputum culture.
RX: Vibramycin 200mg daily, for five days. (First dose today)
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. After questioning further,
I find he had MRSA with multiple skin lesions, however was treated timely and aggressively and there
were no indications of further complications. Due to his history and new symptoms, I am concerned
about the possibility of a progressing infection; we discussed the possibility of a systemic
infection. He is to follow-up with me tomorrow.
I recommended his daughter pick him up, stay with him tonight and come with him tomorrow. I
discussed all of this over the phone with his daughter and she is in agreement. She will pick him
up today. He is to call me immediately if his fever elevates to 100.5 or greater,
or his cough or SOB worsens during the night. He is to discontinue Nyquil. Continue home meds.
Once we are over this episode, schedule an eye exam.
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
Personal Hx. MRSA, V12.04
R/O Systemic infection
William Banister, M.D.
Electronically signed 6/22/10 11:42 am.