Medical records
Faxed the afternoon of July 19 to Gradient Genetech, under cover to Dr. Jean Grey:
Date: February 3, 2005
Location: Office of Dr. [blacked out], Philadelphia, PA
History
Patient ID
Name: Sebastian Hiram Shaw
DOB: January 1, 1963
POB: Pittsburgh, PA
Address: not given
Source
None (self-referred). No primary care physician given.
CC
None. Hx of present illness N/A.
PMHx
Surgical: appendectomy, 1971 (routine, no complications)
Medical: appendicitis, 1971; cracked L tibia, 1989; broken R hand, 1998
Hospitalizations: appendicitis/appendectomy, 1971; treatment of 1989 and 1998 fractures was outpatient
Other serious illnesses or injuries: none
Childhood illnesses: rubella, chicken pox, mumps (all followed normal course)
Immunizations: standard course, all current; next tetanus booster, 2008
Allergies: none
Medications: none (past or current)
Drug allergies: none
FHx
Maternal grandparents: Evelyn Smith Walker, d. at 45 of stroke (hypertension); Grant Walker, d. at 67 of lung cancer (smoking)
Paternal grandparents: Ada Edwards Shaw, d. at 74 of myocardial infarction (smoking, coronary disease); Cornelius Shaw, d. at 58 of myocardial infarction (smoking, alcoholism, hypertension)
Maternal siblings: none
Paternal siblings: Esua Shaw, d. at 38 in coal-mining accident (no significant MHx)
Mother: Celia Walker Shaw, d. at 39 of suicide (no significant MHx)
Father: Jacob Shaw, d. at 47 of pancreatic cancer (smoking, alcoholism, hypertension)
Spouse: none
Children: none
PSHx
Marital status: single/never married (fiancée d. in 1988 car accident, no significant MHx)
Education: Penn State University, College of Engineering - B.S. Electrical Engineering with Engineering Mechanics minor (magna cum laude), 1985; M.Engr. Industrial Engineering, 1988
Occupation: chief executive officer of Shaw Industries (Pittsburgh, PA; New York City, NY)
Number of hours worked: avg. 60-70/week
Lifestyle/preventive health
Exercise: cardiovascular/weight training, avg. 60 minutes @ 3-4 times/week
Sleep: avg. 6-7 hours/night
Diet: avg. 2-3 meals/day; prefers large portions (within normal range for weight/build); follows nutritional guidelines
Caffeinated beverages: avg. 3 cups/day
Smoking: started ~15yo, has quit several times (most recent: 1998-2002), avg. 2 cigars/week
Alcohol: started ~16yo, frequent long spans of abstinence (~2-3 years at a time), no alcoholic tendencies reported, avg. 3-4 drinks/week
Recreational drug use: none
Sexual activity: no current partner; last monogamous relationship, 1986-88 (girlfriend/fiancée); no known STDs; last HIV test negative (2004); uses standard protection
Last complete exam: June 2002 (NYC, records N/A)
Systems review
Constitutional: recent weight gain (~9 lbs.), occasional fatigue (recent)
Eyes: blurry vision (slight, not recent), occasional dryness
ENT: slight tinnitus, frequent dryness of mouth, occasional hoarseness, occasional difficulty in swallowing
Cardiovascular: elevated blood pressure, occasional changes in heart beat, occasional irregular heart beat
Respiratory: infrequent shortness of breath
Gastrointestinal: infrequent heartburn (not recent), infrequent nausea (not recent), infrequent polyphagia
Genitourinary: occasional hesitancy and cloudy urine, occasional polyuria, last prostate exam clear (2004)
Musculoskeletal: infrequent morning stiffness (<30 minutes), occasional muscle tenderness, infrequent muscle weakness (slight, not recent), occasional joint pain (R knee)
Integumentary: no problems reported
Neurological: frequent headaches (dull, pounding, <1 hour), occasional dizziness/vertigo (not recent), rare LOC (not recent), infrequent muscle spasms, infrequent sensitivity and pain in feet (recent)
Psychiatric: slight anxiety, temper control, recent depression/agitation, recent changes in sleeping patterns (late-onset insomnia), no previous illnesses or treatment
Endocrine: occasional polydipsia, occasional weight changes, diabetic symptoms (more recent)
Hematological/lymphatic (circulatory): no problems reported
Allergic/immunological: no problems reported
Physical Exam
Vital statistics
Height: 6'2"
Weight: 218#
Pulse: 72
Respiration: 23
Blood pressure: 130/85
Temperature: 99.2°
Head
Normal palpation of scalp and skull. No bumps, breaks, or weaknesses appreciated.
Eyes
Vision: 20/15 binocular (20/15 R, 20/10 L) as tested with standard eye chart
Pupils: equally round and responsive (slightly heightened response)
EOMs: normal (slightly heightened reactions)
Ears
Hearing: slight loss on R side
Structures: all normal
Conduction: Weber and Rinne test produced slightly heightened response
Nose
No sinus tenderness. Normal hasal mucosa.
Mouth
Structures appear normal.
Neck nodes
Normal assessment.
Thyroid
Normal palpation. Lymph nodes normal.
Respiratory
Inspection: chest wall appearance and spine curvature normal, chest wall motion slightly elevated
Palpation: normal
Percussion: normal
Auscultation: breath sounds normal on both sides at all levels (slightly elevated rate of respiration)
Cardiac
Inspection: chest wall movement normal, jugular veins appear slightly enlarged and prominent
Palpation: carotid arteries slightly enlarged, apical impulse normal
Auscultation: heart sounds normal in all areas; aortic, pulmonary, and carotid sounds all slightly loud (within normal range); normal responses with supine, sitting, and leaning-forward positions
Abdominal
Inspection: normal appendectomy scar, no abnormal masses or pulsations
Palpation: no signs of pain or discomfort, liver and spleen appreciably enlarged, aorta slightly enlarged
Percussion: normal liver span and spleen
Auscultation: normal bowel sounds, normal renal arteries, aorta (midline) slightly loud
Neurological
Cranial nerves: I - olfaction slightly depressed (within normal range); II - see HEENT; III-VI - see HEENT; V - normal cheek/jaw touch response and jaw clench; VII - normal motions of eyebrows, eyelids, and lips; VIII - see HEENT; IX-X - normal uvular response; XI - normal shrug motion; XII - normal tongue protrusion
Cerebellar tests: rapid alternating movements - above-normal; finger-to-nose-to-finger - above-normal; heel-to-shin - normal; gait - normal, with slight hesitation on R (knee/ankle); Rhomberg - normal
Sensory tests: sharp vs. dull - slightly above-normal; light touch - slightly above-normal; vibration test - distal extremities slightly above-normal (further testing not indicated); motor functions - all slightly above-normal except small muscle strength and hand grip (appreciably above-normal); position sense - normal; reflexes - all appreciably above-normal (tendons, biceps, branchioradialis, triceps, patellar, Achilles, plantar)
Mental
Orientation: correctly stated date and location
Registration: correctly named three objects, repeated, and learned on first trial
Attention and calculation: correctly counted serial sevens backward from 100
Recall: correctly recalled all three objects from registration test
Language and praxis: performed all tests correctly (naming two common objects, repeating phrase, obeying three-stage command, reading and obeying sign, writing sentence, copying design)
Musculoskeletal
Muscle strength groups: all appreciably above-normal
Cervical spine: normal palpation, ROM, extension, rotation, side-to-side, and chin-to-chest
Shoulders: normal ROM (active and passive)
Elbows: normal palpation of medial and lateral epicondyles, normal ROM (slight hestitation on extension)
Wrists: normal palpation of carpal tunnels, radial heads, and ulnar styloid processes
Hands: normal ROM (slight stiffness on R)
Back: normal inspection and palpation of spinous processes, decreased LS ROM (within normal parameters), decreased straight leg raise (especially on L)
Hips: decreased ROM (within normal parameters)
Knees: decreased ROM on R (especially extension), normal stability (slightly decreased on R)
Ankles: normal ROM
The last page of the record, obtained separately (original, not a copy) and not faxed with the rest:
Summary
Patient presents as 42-year-old Caucasian male in general good health with symptoms of the following: stress, mild hypertension, depression, and possible Type I diabetes (insulin-dependent diabetes mellitus).
Physical constitution is excellent for his age. Muscle density, tone (tension), and performance reflect obvious genetic advantage as well as the benefit of a long-term exercise regimen. Motor reflexes are also extraordinary; sensory reactions show less but still significant improvement over normal, especially in visual and touch acuity. Encouraged patient to continue exercise plan, with added rest time built in to improve recovery. Further suggested additional flexibility exercises, particularly for hips and lower extremities; recommended yoga in particular, which would also provide ameliorating effect on stress, hypertension, and mental status.
Patient's affect was cool and formal, occasionally distracted and then impatient when recalled to interview or exam. Patient remained polite throughout, but admitted to emotional lability under close, conscious control. Believe it to be connected, along with the depression, anxiety, and stress, to some recent traumatic event (none such offered in explanation by patient), perhaps related to his occupation. Prescription for antidepressants or sleeping pills and suggestion of professional counselling also declined, AMA. Underlined the importance of exercise, rest, and diet to let mind and body recuperate. Patient agreed to make increased effort in those areas, and to cut back on caffeine, alcohol, smoking, and workload (the idea of taking a vacation was flatly rejected).
Patient reported that battery of blood-glucose tests performed after last complete exam (2002) not conclusive for IDDM. Directed him to endocrinology specialist, Dr. [blacked out] at [blacked out], without much hope of an actual appointment ever being made. Patient seemed reluctant even to consider diagnosis, let alone agree to testing and then treatment. Patient determined to solve problems himself, with only token gestures at supportive medical care, and my strong disapproval and repeated arguments for closer monitoring made no apparent dent in this attitude.
Was not expecting to see this patient again, so provided copy of all medical records at the time upon request for his next physician. Patient paid in cash before departing. Have since been served with restraining order on releasing these records for any reason, upon pain of severe judicial and professional punishment. Filed a complaint with state medical board; received official rebuke for abusing the system, with suggestion of exploring employment options out of state (or country) in case of any further complaints or other attention brought to bear on this particular situation.
End of record.
Date: February 3, 2005
Location: Office of Dr. [blacked out], Philadelphia, PA
History
Patient ID
Name: Sebastian Hiram Shaw
DOB: January 1, 1963
POB: Pittsburgh, PA
Address: not given
Source
None (self-referred). No primary care physician given.
CC
None. Hx of present illness N/A.
PMHx
Surgical: appendectomy, 1971 (routine, no complications)
Medical: appendicitis, 1971; cracked L tibia, 1989; broken R hand, 1998
Hospitalizations: appendicitis/appendectomy, 1971; treatment of 1989 and 1998 fractures was outpatient
Other serious illnesses or injuries: none
Childhood illnesses: rubella, chicken pox, mumps (all followed normal course)
Immunizations: standard course, all current; next tetanus booster, 2008
Allergies: none
Medications: none (past or current)
Drug allergies: none
FHx
Maternal grandparents: Evelyn Smith Walker, d. at 45 of stroke (hypertension); Grant Walker, d. at 67 of lung cancer (smoking)
Paternal grandparents: Ada Edwards Shaw, d. at 74 of myocardial infarction (smoking, coronary disease); Cornelius Shaw, d. at 58 of myocardial infarction (smoking, alcoholism, hypertension)
Maternal siblings: none
Paternal siblings: Esua Shaw, d. at 38 in coal-mining accident (no significant MHx)
Mother: Celia Walker Shaw, d. at 39 of suicide (no significant MHx)
Father: Jacob Shaw, d. at 47 of pancreatic cancer (smoking, alcoholism, hypertension)
Spouse: none
Children: none
PSHx
Marital status: single/never married (fiancée d. in 1988 car accident, no significant MHx)
Education: Penn State University, College of Engineering - B.S. Electrical Engineering with Engineering Mechanics minor (magna cum laude), 1985; M.Engr. Industrial Engineering, 1988
Occupation: chief executive officer of Shaw Industries (Pittsburgh, PA; New York City, NY)
Number of hours worked: avg. 60-70/week
Lifestyle/preventive health
Exercise: cardiovascular/weight training, avg. 60 minutes @ 3-4 times/week
Sleep: avg. 6-7 hours/night
Diet: avg. 2-3 meals/day; prefers large portions (within normal range for weight/build); follows nutritional guidelines
Caffeinated beverages: avg. 3 cups/day
Smoking: started ~15yo, has quit several times (most recent: 1998-2002), avg. 2 cigars/week
Alcohol: started ~16yo, frequent long spans of abstinence (~2-3 years at a time), no alcoholic tendencies reported, avg. 3-4 drinks/week
Recreational drug use: none
Sexual activity: no current partner; last monogamous relationship, 1986-88 (girlfriend/fiancée); no known STDs; last HIV test negative (2004); uses standard protection
Last complete exam: June 2002 (NYC, records N/A)
Systems review
Constitutional: recent weight gain (~9 lbs.), occasional fatigue (recent)
Eyes: blurry vision (slight, not recent), occasional dryness
ENT: slight tinnitus, frequent dryness of mouth, occasional hoarseness, occasional difficulty in swallowing
Cardiovascular: elevated blood pressure, occasional changes in heart beat, occasional irregular heart beat
Respiratory: infrequent shortness of breath
Gastrointestinal: infrequent heartburn (not recent), infrequent nausea (not recent), infrequent polyphagia
Genitourinary: occasional hesitancy and cloudy urine, occasional polyuria, last prostate exam clear (2004)
Musculoskeletal: infrequent morning stiffness (<30 minutes), occasional muscle tenderness, infrequent muscle weakness (slight, not recent), occasional joint pain (R knee)
Integumentary: no problems reported
Neurological: frequent headaches (dull, pounding, <1 hour), occasional dizziness/vertigo (not recent), rare LOC (not recent), infrequent muscle spasms, infrequent sensitivity and pain in feet (recent)
Psychiatric: slight anxiety, temper control, recent depression/agitation, recent changes in sleeping patterns (late-onset insomnia), no previous illnesses or treatment
Endocrine: occasional polydipsia, occasional weight changes, diabetic symptoms (more recent)
Hematological/lymphatic (circulatory): no problems reported
Allergic/immunological: no problems reported
Physical Exam
Vital statistics
Height: 6'2"
Weight: 218#
Pulse: 72
Respiration: 23
Blood pressure: 130/85
Temperature: 99.2°
Head
Normal palpation of scalp and skull. No bumps, breaks, or weaknesses appreciated.
Eyes
Vision: 20/15 binocular (20/15 R, 20/10 L) as tested with standard eye chart
Pupils: equally round and responsive (slightly heightened response)
EOMs: normal (slightly heightened reactions)
Ears
Hearing: slight loss on R side
Structures: all normal
Conduction: Weber and Rinne test produced slightly heightened response
Nose
No sinus tenderness. Normal hasal mucosa.
Mouth
Structures appear normal.
Neck nodes
Normal assessment.
Thyroid
Normal palpation. Lymph nodes normal.
Respiratory
Inspection: chest wall appearance and spine curvature normal, chest wall motion slightly elevated
Palpation: normal
Percussion: normal
Auscultation: breath sounds normal on both sides at all levels (slightly elevated rate of respiration)
Cardiac
Inspection: chest wall movement normal, jugular veins appear slightly enlarged and prominent
Palpation: carotid arteries slightly enlarged, apical impulse normal
Auscultation: heart sounds normal in all areas; aortic, pulmonary, and carotid sounds all slightly loud (within normal range); normal responses with supine, sitting, and leaning-forward positions
Abdominal
Inspection: normal appendectomy scar, no abnormal masses or pulsations
Palpation: no signs of pain or discomfort, liver and spleen appreciably enlarged, aorta slightly enlarged
Percussion: normal liver span and spleen
Auscultation: normal bowel sounds, normal renal arteries, aorta (midline) slightly loud
Neurological
Cranial nerves: I - olfaction slightly depressed (within normal range); II - see HEENT; III-VI - see HEENT; V - normal cheek/jaw touch response and jaw clench; VII - normal motions of eyebrows, eyelids, and lips; VIII - see HEENT; IX-X - normal uvular response; XI - normal shrug motion; XII - normal tongue protrusion
Cerebellar tests: rapid alternating movements - above-normal; finger-to-nose-to-finger - above-normal; heel-to-shin - normal; gait - normal, with slight hesitation on R (knee/ankle); Rhomberg - normal
Sensory tests: sharp vs. dull - slightly above-normal; light touch - slightly above-normal; vibration test - distal extremities slightly above-normal (further testing not indicated); motor functions - all slightly above-normal except small muscle strength and hand grip (appreciably above-normal); position sense - normal; reflexes - all appreciably above-normal (tendons, biceps, branchioradialis, triceps, patellar, Achilles, plantar)
Mental
Orientation: correctly stated date and location
Registration: correctly named three objects, repeated, and learned on first trial
Attention and calculation: correctly counted serial sevens backward from 100
Recall: correctly recalled all three objects from registration test
Language and praxis: performed all tests correctly (naming two common objects, repeating phrase, obeying three-stage command, reading and obeying sign, writing sentence, copying design)
Musculoskeletal
Muscle strength groups: all appreciably above-normal
Cervical spine: normal palpation, ROM, extension, rotation, side-to-side, and chin-to-chest
Shoulders: normal ROM (active and passive)
Elbows: normal palpation of medial and lateral epicondyles, normal ROM (slight hestitation on extension)
Wrists: normal palpation of carpal tunnels, radial heads, and ulnar styloid processes
Hands: normal ROM (slight stiffness on R)
Back: normal inspection and palpation of spinous processes, decreased LS ROM (within normal parameters), decreased straight leg raise (especially on L)
Hips: decreased ROM (within normal parameters)
Knees: decreased ROM on R (especially extension), normal stability (slightly decreased on R)
Ankles: normal ROM
The last page of the record, obtained separately (original, not a copy) and not faxed with the rest:
Summary
Patient presents as 42-year-old Caucasian male in general good health with symptoms of the following: stress, mild hypertension, depression, and possible Type I diabetes (insulin-dependent diabetes mellitus).
Physical constitution is excellent for his age. Muscle density, tone (tension), and performance reflect obvious genetic advantage as well as the benefit of a long-term exercise regimen. Motor reflexes are also extraordinary; sensory reactions show less but still significant improvement over normal, especially in visual and touch acuity. Encouraged patient to continue exercise plan, with added rest time built in to improve recovery. Further suggested additional flexibility exercises, particularly for hips and lower extremities; recommended yoga in particular, which would also provide ameliorating effect on stress, hypertension, and mental status.
Patient's affect was cool and formal, occasionally distracted and then impatient when recalled to interview or exam. Patient remained polite throughout, but admitted to emotional lability under close, conscious control. Believe it to be connected, along with the depression, anxiety, and stress, to some recent traumatic event (none such offered in explanation by patient), perhaps related to his occupation. Prescription for antidepressants or sleeping pills and suggestion of professional counselling also declined, AMA. Underlined the importance of exercise, rest, and diet to let mind and body recuperate. Patient agreed to make increased effort in those areas, and to cut back on caffeine, alcohol, smoking, and workload (the idea of taking a vacation was flatly rejected).
Patient reported that battery of blood-glucose tests performed after last complete exam (2002) not conclusive for IDDM. Directed him to endocrinology specialist, Dr. [blacked out] at [blacked out], without much hope of an actual appointment ever being made. Patient seemed reluctant even to consider diagnosis, let alone agree to testing and then treatment. Patient determined to solve problems himself, with only token gestures at supportive medical care, and my strong disapproval and repeated arguments for closer monitoring made no apparent dent in this attitude.
Was not expecting to see this patient again, so provided copy of all medical records at the time upon request for his next physician. Patient paid in cash before departing. Have since been served with restraining order on releasing these records for any reason, upon pain of severe judicial and professional punishment. Filed a complaint with state medical board; received official rebuke for abusing the system, with suggestion of exploring employment options out of state (or country) in case of any further complaints or other attention brought to bear on this particular situation.
End of record.