Sample Report: History and Physical: Asbestosis
CHIEF COMPLAINT: The patient is a middle-aged male who is complaining of increasing shortness of breath on exertion.
HISTORY OF PRESENT ILLNESS: The patient has always been an active individual and takes advantage of activities that require a high degree of physical involvement. For aboutthe past year he has been preparing himself to run in a 20-mile marathon. In the past 6 weeks or so, however, he has noticed that he becomes short of breath much quicker than usual and states that he has actually become too fatigued to work out at all.
Outpatient x-ray revealed pleural calcifications along the costal margins bilaterally within the mid lung fields.
Linear calcification is noted overlying the left hemidiaphragm.
PAST HISTORY: He has had several bouts of severe bronchitis and was hospitalized once with pneumonia. He was also hospitalized in the past for cholecystectomy and appendectomy.
SOCIAL HISTORY: The patient has installed insulation for a living for many years, starting in his early teens when he helped in his father's business. The patient is a nonsmoker and no one in the home smokes.
FAMILY HISTORY: His mother is in her 80s and in reasonably good health. His father died of mesothelioma in his mid 60s. There are 2 brothers and 3 sisters, all in good health. He is the only one of his brothers and sisters to work in the insulation business.
REVIEW OF SYSTEMS: Negative except as noted. Eyes: Has worn glasses for several years. He denies blurred vision or difficulty seeing to drive at night. His last exam was 2 years ago. Respiratory: Notes a morning cough that produces approximately 1 teaspoon of grayish sputum.
PHYSICAL EXAMINATION: GENERAL: The patient states that he feels exhausted, but he is in good spirits. VITAL SIGNS: Within normal limits. SKIN: There are no rashes or petechiae. There is a tattoo of a motorcycle on his left upper arm and one of an eagle on his mid back. HEENT: Pupils are regular and reactive to light and accommodation. Extraocular movements are intact. NECK: Normal range of motion is noted. There is no lymphadenopathy or tenderness. Thyroid exam reveals no abnormality. CHEST: Normal symmetry with respirations. No tenderness. Crackles are heard throughout. HEART: Normal S1, S2. No rhythm abnormality is detected.
ABDOMEN: The abdomen is flat and nontender. Scars are consistent with the noted surgical procedures. Bowel sounds are normal, and there are no bruits. No inguinal adenopathy. GENITALIA: Normal male genitalia. RECTAL: Not done at this time.
MUSCULOSKELETAL: Range of motion is normal. No joint pain or swelling noted.
NEUROLOGIC: Cranial nerves II through XII are normal.
IMPRESSION: The patient is admitted for further tests and pulmonary consultation as indicated by the history and physical examination. We are most likely dealing with asbestosis, but we need to rule out mesothelioma. A CT scan has been ordered.
ADMITTING DIAGNOSIS: Probable asbestosis.