MND12MPMillerJenny4/18/94 9:40 a.m.474917806/1/94 10:13 am1155298/19/65Female5/28/1994Dr SocratesBlue CrossDiabetes Research GroupAbnormal Uterine Bleeding1Clinic1FTTTFF474917801001FTTTGordonBen5/30/94 3:45 pm475526256/4/94 8:00 am22332/12/94Male5/30/1994Dr SocratesBlue CrossDiabetes Research GroupDizziness032Clinic1FFTTFF475526252001FTTTMND13MEET1474917804/18/94 9:40 a.m.4749178010011F4/18/94 9:40 a.m.00:450TTTTSTHISTORY

FDLMP: 1/23/95, Menarch 13, Regular, duration 5d, frequency q 29d, 5 pads per day, 

- passing tissue, + passing clots, + postcoital bleeding, + intermenstrual bleeding, 

- vasomotor flushes, - changes in hair/skin/texutre/distribution, + abdominal pain, 

- fever ,- chills, + lightheadedness, + nausea, pregnancy is possible, 

+ emotional stress, + weight changes, + tricyclic antidepressives, - thyroid symptoms, 

grav 0, para 0, + diet pills, - IUD, - family history, 10240OTPHYSICAL EXAM

hemodynamically stable, 

minimal bleeding,

- orthostatic hypotension

GYN

+ cervical lesions x 1 cm anterior, 

- clitoromegally, 

+ cervical motion tenderness, 

Uterus size normal, 

GENERAL

- skin/hair changes, 

- thyroid, 

- galactorrhea, 

+ obesity, 

- hirsuitism, 

10240ATPRIMARY

Diet pills, R/O Tricyclic antidepressives

SECONDARY

Obesity10240PTD/C diet pills, increase exercise, 10240LTCBC -

Lytes -

Serum hCG -

PAP pending

GC pending

Chlamydia -

Guiac - x 3

LFTUs  -

Thyroid panel -

LH/FSH -

PT/PTT -10240GIRTET2475526255/30/94 3:45 pm4755262520011F5/30/94 3:45 pm00:450TTTTSTSensation of spinning x 4 days, 

+ Faintness/lightheadedness, 

-blurred vision, 

worse with change in position, 

worse with coughing, 

- hyperventilation, 

-nausea, 

+postural unsteadiness, 

- weakness, 

- headache, 

- vomiting, 

-tinnitis, 

- head trauma, 

- ototoxic drugs, 

- diplopia, 

- parasthesias, 

+ Hypertension, 

- CVD. 

+ antihypertensives x 3 weeks10240OTPHYSICAL EXAM: 

+ valsalva, 

+Orthostatic hypotension

HEENT

-sensory changes, 

visual acuity 20/20 OU, 

-tympanic membrane inflammation, 

- dizziness on head turning 

- Rinne, 

- Webber

HEART

Rhythm Regular, 

- murmurs

NEURO

A&O x4,

-sensory loss or changes, 

- ataxia, 

- weakness, 

CN II-XII intact, 

U/L Reflexes 2/4. 

- BabinskiUs, 

good coordination

RECTAL

- occult blood10240ATPRIMARY

Orthostatic Hypotension

SECONDARY

Antyhypertensive therapy10240PT10240LTCBC -

Lytes -

MRI -10240GIRTTylenol, 200mg2 capsulesbefore mealsDailyfor 18 days30 capsules2 refillsNo SubstitutionMND14LC