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HISTORY/PHYSICAL EXAMINATION

DATE: 21/1/2016
NAME: Richard Solomon
CHIEF COMPLAINT: Patient is a 56-year old, single black male who was here for a
yearly exam. He states she has been feeling well and has no specific concerns.
SOCIAL HISTORY: He is currently working as a sales representative for a software
company.
PAST MEDICAL HISTORY: ALLERGIC TO SULFUR DRUGS. Does not smoke. Has not
had any major illnesses.
FAMILY HISTORY: Maternal grandmother had breast cancer; father had diabetes.
REVIEW OF SYSTEMS: No complaints.
PHYSICAL EXAMINATION: N/A
HEENT: Negative.
NECK: Thyroid is normal.
HEART, LUNGS, AND ABDOMEN: Within normal limits.
IMPRESSION: Normal Exam.
PLAN: Return to clinic 1 year, sooner PRN.
David Green, M.D. /mj

HISTORY/PHYSICAL EXAMINATION

DATE: 6/27/2016
NAME: Sherman Tate
CHIEF COMPLAINT: Trouble with vision.
SUBJECTIVE: Patient is a 65-year old male who had 2 episodes during the last week
of jagged lights occurring in central vision field. These lasted 15-20 minutes; no
other symptoms.
PAST MEDICAL HISTORY: Patient has a long history of migraines.
PHYSICAL EXAMINATION: All within normal limits; specifically, no tear or hole of
the retina.
ASSESSMENT: Migraine equivalent vs. posterior vitreous detachment.
PLAN:
1. Discussed with ophthalmologist, Dr. Lauren Golifi. Patient advised about signs
and symptoms of detachment of the retina and told to seek immediate
medical attention should any of these signs appear.
2. Trial of Inderal 40 mg. b.i.d. for migraines.
3. Recheck in 1 to 2 months.
4. Patient requests referral to Dr. Grolifi.
Newman Gladen, M.D. /mj

HISTORY/PHYSICAL EXAMINATION
DATE: 2/1/2016
NAME: Karen Brill
CHIEF COMPLAINT: Karen has complaints of coughing with yellowish green
septum, fever, sinus congestion, bilateral ear pain, swollen node in her neck,
dizziness, and vertigo.
SOCIAL HISTORY: She is working as a concierge in a major hotel.
PAST MEDICAL HISTORY: No major past illness.
FAMILY HISTORY: Mother has emphysema.
EXAMINATION: Temperature is 99.4F.
ENT: TMs are clear. Maxillary sinus regions are tender bilaterally. Throat is clear
NECK: Reveals a 1-cm tender anterior cervical node on the right.
HEART: Tones are normal.
LUNGS: Reveal basilar rales that partially clear with deep breathing.
ABDOMEN: Negative.
NEUROLOGICAL EXAM: Awake, alert, and oriented. Good strength in all groups.
Sensation is intact to light touch. Deep tendon reflexes are 11 and equal
bilaterally. Cranial nerves II-XII are intact. Cerebellar testing including finger-tonose is within normal limits. She has horizontal gaze nystagmus bilaterally with
no vertical nystagmus. Vertigo seems to be worse with sitting or moving head.
LABORATORY: White count is 7600. Chest X-ray shows bilateral breast implants but
is negative for infiltrate or congestive failure. Sinus films show mucosal thickening
on the right but are otherwise negative.
ASSESSMENT:
1. URI with sinusitis, pharyngitis, and bronchitis in a smoker.
2. Acute labyrinthitis.
TREATMENT: Patient was given Valium 2.5 mg VIV with marked improvement in her
vertigo. She was prescribed Biaxin 500 mg BID x 10 days; Antivert 25 mg TID PRN
for dizziness; and Tylenol PRN for discomfort. She is to get plenty of rest, push
fluids, and AVOID SALTY PRODUCTS. Have patient return in 48 hours if symptoms
persist.
Marshall Peck, M.D. /mj