Chapter 5: The Lymphatic and Immune Systems | William Shumaker's Chart Note

CHART NOTE

Patient Name: Shumaker, William
ID Number: WS3671
Examination Date: May 2, 20xx

SUBJECTIVE
Mr. William Shumaker is a 57-year-old male accountant who is new to this practice. He has noticed a painless lump on the right side of his neck. He states that he is very tired, has been experiencing night sweats, and has lost about 8 pounds in the past 2 months.

OBJECTIVE
Low-grade fever. BP (blood pressure), pulse, and respiration within normal limits. There are 2 firm enlarged lymph nodes on the right side of the neck, to the right and just below the laryngeal prominence (Adam's apple).

ASSESSMENT
Lymphadenopathy. Rule out Hodgkin's disease.

PLAN
CBC (complete blood count) and chest X-ray will be scheduled along with a biopsy.


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