1 of 8 Patient: Webster, Brooke Address: 1925 Stone St Port Huron, MI 48060 Date of Birth: November 12, 1978 Visit Date: 07/15/2020 Patient: Webster, Brooke 1925 Stone St Port Huron, MI 48060 DOB: 11/12/1978 Sex: Female Phones: home: (810)292-2764 Status: Complete. Visit Last Changed: 08/15/2020 12:54 AM CC / HPI: She presented with joint complaint. The symptoms are mostly affecting the Left Shoulder. The quality is described as dull pain. The severity is 5 / 10 at best, 8 / 10 at worst and 5 / 10 today. The symptom is ongoing. The symptom started 9 months ago. The complaint mildly limits activities. The frequency of episodes is constant. Episodes occur constant. Important triggers include overuse. The symptom is alleviated by medication. Pertinent findings include joint weakness and joint stiffness. In addition, she presented with transient ischemic attack. The episode occured 12/2018. The symptoms were/was visual changes, numbness of left upper extremity and numbness left lower extremity. The patient was admited to the hospital for treatment.The patient is on the following medications for stroke prevention: none. The patient also presented with numbness. The quality is described as tingling. It is located on the left foot and on the left leg. The symptom started 2018 years ago. The frequency of episodes is increasing. Episodes occur constant. Important triggers include none known. The symptom is alleviated by none known. The symptom is ongoing. The complaint moderately limits activities. She next presented with fatigue. The symptom is ongoing. The complaint moderately limits activities. The frequency of episodes is increasing. The symptom started 12/2018 years ago. Current Medication: furosemide 20 mg tablet, oral. Adderall 10 mg tablet, oral. metoprolol tartrate 25 mg tablet, oral. Review of history: I reviewed the documented medical, family, social, medication, drug allergy and problem/diagnosis histories. ROS: Cardiovascular: The patient complained of edema but denied arrhythmia, chest pain/pressure, claudication, congestive heart failure, coranary artery disease, diaphoresis, dyslipidemia, dyspnea, dyspnea on exertion, exercise intolerance, fatigue, hypertension, near-syncope/dizziness, orthopnea, pacemaker implant, pain in calf with walking, paroxysmal nocturnal dyspnea, reduced exercise Generated on 7/29/2021 2 of 8 Patient: Webster, Brooke Address: 1925 Stone St Port Huron, MI 48060 Date of Birth: November 12, 1978 intolerance and tachycardia. Allergy/Immunology: The patient denied angioedema, food allergy, rhinitis, urticaria, wheezing and anaphylactoid reaction. Dermatologic: The patient complained of hair loss but denied rash, pruritus, eczema, changing moles, dermatitis - seborrheic, ecchymosis, herpes simplex, hyperhidrosis, impetigo, keloid, lupus erythematosus, melanoma, molluscum contagiosum, neoplasm, psoriasis, skin lesion and tinea. Ears/Nose/Throat/Neck: The patient complained of tinnitus, lightheaded and dysequilibrium but denied hearing loss, vertigo and sinus congestion. Eyes: The patient complained of blurred vision, ptosis (droopy eyelid) and wears glasses/contacts but denied amblyopia, cataract, diabetic retinopathy, double vision, glaucoma, macular degeneration, vision change and visual disturbance. Gastrointestinal: The patient complained of heartburn but denied nausea, abdominal pain, hepatitis and constipation. Genitourinary/Nephrology: The patient complained of urinary incontinence but denied chronic renal failure, kidney stones, erectile dysfunction, number of pregnancies _ and number of miscarriages _. Hematologic/Lymphatic: The patient denied abnormal bleeding and bruising, history of blood transfusion, abnormal ecchymoses, petechiae, history of blood clots, anemia, arterial thrombosis and lymph node enlargement/mass. Musculoskeletal: The patient complained of shoulder pain, knee pain, neck pain, thoracic spine pain and low back pain but denied arthritis, wrist pain, carpal tunnel syndrome, elbow pain, hip pain, ankle pain, muscle spasms and muscle pain. Neurologic: The patient complained of headache, numbness, dizziness, gait abnormality and memory loss but denied seizure, tremors, history of stroke / TIA, head injury and weakness. Psychiatric: The patient complained of anxiety and depression but denied difficulty with concentration, hallucinations, disturbances of memory, uncontrolled Laughing, uncontrolled Crying, hallucination and suicidality. Sleep: The patient complained of excessive daytime drowsiness but denied difficulty maintaining restful sleep, snoring, stoppage of breathing during sleep, restless legs syndrome and insomnia. Respiratory: The patient complained of shortness of breath but denied cough and wheezing. Vital Signs: Collected Weight Height BMI Temp RR HR BP BP 2 Head Circ SpO2 Waist 07/15/2020 09:54 AM By: Minor, Shannon 131 lbs 5' 3'' 23.2 99 F 16 bpm 79 bpm 130/75 mmHg 98 % PE: Constitutional general appearance Generated on 7/29/2021 3 of 8 Patient: Webster, Brooke Address: 1925 Stone St Port Huron, MI 48060 Date of Birth: November 12, 1978 nourishment: well nourished evidence of Distress: in no acute distress assistive Device: none Eyes extraocular muscles left eye movement: intact right eye movement: intact conjunctiva/eyelids overall: conjunctiva clear and eyelids normal left eyelid: benign right eyelid: benign pupils and irises left pupil: round and reactive to light right pupil: round and reactive to light Ears/Nose/Throat hearing assessment overall: hearing intact bilaterally left gross exam: intact right gross exam: intact lips/teeth/gingiva overall: benign gingiva and benign lips lips: normal gingiva: normal oral cavity/pharynx/larynx overall: oral mucosa clear Neck supple general supple and no masses thyroid overall: nontender inspection of neck overall: no masses Respiratory palpation of chest overall: normal excursion, no pain respiratory effort/rhythm overall: no retractions and normal rate Cardiovascular auscultation of heart overall: regular rate rhythm: regular rhythm extremities overall: no cyanosis and no clubbing edema present: no edema Abdomen abdominal exam overall: no tenderness contour: non distended Musculoskeletal head and neck trigger points no trigger point tenderness noticed head: atraumatic and normocephalic spine, ribs and pelvis Generated on 7/29/2021 4 of 8 Patient: Webster, Brooke Address: 1925 Stone St Port Huron, MI 48060 Date of Birth: November 12, 1978 spine: decreased cervical flexion, normal cervical lateral flexion, decreased cervical extension, normal lumbar extension, normal lumbar flexion, tender @ thoracic spine, tender @ lumbar spine, tender @ cervical spine and normal straight leg raise sacroiliac joints: nontender right upper extremity overall: right shoulder benign left upper extremity overall: normal left shoulder palpation - left upper arm: AC joint tenderness and tenderness right lower extremity overall: right knee benign left lower extremity overall: left knee benign gait and station station: straight spine Integument inspection of skin overall: no rash is seen consistency: moist palpation overall: no induration, no tenderness Neurologic deep tendon reflexes overall: DTR's are intact and symmetrical reflexes plantar reflex negative bilaterally sensation overall: abnormal sensation lower extremities - left, abnormal sensation lower extremities - right, abnormal sensation upper extremities - left and abnormal sensation upper extremities - right mental status overall: oriented and alert language: no dysarthria and no aphasia gait overall: no ataxia, no unsteadiness romberg test: negaitive coordination overall: no dysdiadochokinesis, no dysmetria and no tremors cranial nerves overall: cranial nerves 1-12 intact motor overall: normal bulk, tone strength (graded from 0-5, add X for atrophy): upper extremity strength is 5-/5 pronator drift: no drift Psychiatric orientation/consciousness overall: oriented to person, place and time behavior/psychomotor activity overall: no tics, normal psychomotor activity mood and affect mood: depressed and anxious Dx: Generated on 7/29/2021 5 of 8 Patient: Webster, Brooke Address: 1925 Stone St Port Huron, MI 48060 Date of Birth: November 12, 1978 White matter disease, unspecified Cervicalgia Pain in left leg Leg pain, bilateral Pain in left shoulder Other disturbances of skin sensation Dizziness and giddiness Other visual disturbances Tinnitus Headache Migraine, unspecified, not intractable, without status migrainosus Weakness Hyperthyroidism Essential (primary) hypertension Narcolepsy Pain in thoracic spine Rx: Services Performed: 99205 OFFICE/OUTPATIENT VISIT NEW with this modifier: 25 J1885 Toradol 15mg in a quantity of 4 CC: left shoulder pain Toradol Injection: The risks, benefits and the indication for the injection were provided to the patient verbally. The patient consented. Using a 25 gauge, 1 inch needle, 2 cc of Toradol 30 mg/cc was injected in the patient’s right gluteal. No adverse reactions were seen. The patient tolerated the injection well, and had no complaints after. The patient is to call the clinic with any complications. 96372 Drug Admin/ Subq/IM Calculated Complexity:None Services Ordered: 62270 Spinal Puncture Diagnostic (MS) 20611 Injection major joint (knee or shoulder) w/US (left AC) 97039 PHYSICAL THERAPY TREATMENT 95930 VEP 92540 VAT 92585 AEP Comprehensive 92541 ENG 95812 EEG 41-60 MINUTES 72156 MRI NECK SPINE W/O & W/DYE 70553 MRI BRAIN W/O & W/DYE 72146 MRI Thoracic wo/ Contrast 73030 Shoulder 2V (left) 95861 Two extremities with or w/o paraspinal (upper and lower) Patient Referrals Related To This Visit: Generated on 7/29/2021 6 of 8 Patient: Webster, Brooke Address: 1925 Stone St Port Huron, MI 48060 Date of Birth: November 12, 1978 Bazo, Charbal Plan: A return visit is indicated in 1 month. Impression/Plan: 1. White matter changes/Weakness/Ataxia: The differential diagnosis was discussed with the patient. Patient reports having had difficulty with ambulation and lower Germany weakness over the last few months. Patient had MRI of the brain done 4/9/2019 which showed nonspecific white matter changes. MRI showed approximately 5 areas of abnormal signal as well as trace amount of fluid surrounding the optic nerves. I will update an MRI of the brain with and without contrast. I will schedule the patient for a lumbar puncture for CSF studies for multiple sclerosis. Further treatment options will be discussed with the patient after the testing is completed. 2. Cervicalgia/Thoracic spine pain/Upper extremity pain and numbness: The differential diagnosis was discussed with the patient. Due to the chronicity and severity of the patient’s symptoms, I will order an MRI of the cervical and thoracic spine and I will order a NCS/EMG of the bilateral upper extremities to check for evidence of radiculopathy versus neuropathy. Further treatment options will be discussed with the patient after the testing is completed. 3. Dizziness/Imbalance/Vertigo/Visual changes: The differential diagnosis was discussed with the patient. I will order VAT, ENG, VEP, BAER, and EEG testing to distinguish central verses peripheral causes for the patient’s symptoms. Further treatment options will be discussed after testing is completed. 4. Chronic migraine headaches/Occipital neuritis: The natural history of this condition was discussed with the patient. Treatment options were discussed with the patient. I will order an MRI of the brain as mentioned above. 5. Left shoulder pain/Acromioclavicular joint pain: The natural history of this condition was discussed with the patient. Treatment options were discussed with the patient. I will schedule the patient for ultrasound guided steroid injections. We have had a lengthy discussion with regard to the risks, benefits and side effects of these injections, as well as the potential complications. The patient appears to understand and wishes to proceed. The patient is advised to bring a driver at the time of the injection and to stop any aspirin and its derivatives 7 days prior to the injection. I will get x-rays to evaluate for possible pathology. Further treatment options will be discussed with the patient after the testing is completed. Toradol 60 mg IM was given today. 6. Narcolepsy: The natural history of this condition was discussed with the patient. Patient follows with Dr. Bazo for this. Patient was recently placed on Adderall. 7. Ataxia: The differential diagnosis was discussed with the patient. Patient reports difficulty walking and has been tripping over her own feet. She states her legs get weak with short distance ambulation of about a block. MRI of the brain has been ordered. I have referred her for physical therapy. 8. Memory loss: The differential diagnosis was discussed with the patient. MMSE was 30/30 and 3/3 today. I will order a laboratory workup to check for reversible causes. I will order an EEG to evaluate for possible etiology. Further treatment options will be discussed with the patients after the testing is completed. The history, physical exam, and plan was discussed with Dr. Shuayto and he agreed with the plan. Generated on 7/29/2021 7 of 8 Patient: Webster, Brooke Address: 1925 Stone St Port Huron, MI 48060 Date of Birth: November 12, 1978 Patient History As Of This Visit Medication History: Adderall 10 mg tablet, oral. Active furosemide 20 mg tablet, oral. Active metoprolol tartrate 25 mg tablet, oral. Active Drug Allergy: keflex Problems: Anxiety Hypertension migraines Narcolepsy Thyroid TIA Surgical: hernia repair Family: Relationship: Runs in the family Disease: Alcoholism; Drug Addiction; Depressive disorder; Cancer Recorded Date: July 15, 2020 Social: Marital status Divorced Employment On Disability Tobacco history Former smoker Alcohol history Rare Has the patient ever used illegal drugs? Has never used illegal drugs Has the patient used marijuana? never Electronically signed by: Janette Guertin NP on 07/20/2020 10:22 AM Generated on 7/29/2021 8 of 8 Patient: Webster, Brooke Address: 1925 Stone St Port Huron, MI 48060 Date of Birth: November 12, 1978 Approved by: Marwan Shuayto M.D. on 08/15/2020 12:54 AM Generated on 7/29/2021
