MND12MPMillerJenny4/18/94 9:40 a.m.474917806/1/94 10:13 am1155298/19/65Female5/28/1994Dr SocratesBlue CrossDiabetes Research GroupAbnormal Uterine Bleeding1Clinic1FTTTFF474917801001FTTTGordonBen5/30/94 3:45 pm475526256/4/94 8:00 am22332/12/94Male5/30/1994Dr SocratesBlue CrossDiabetes Research GroupDizziness032Clinic1FFTTFF475526252001FTTTMND13MEET1474917804/18/94 9:40 a.m.4749178010011F4/18/94 9:40 a.m.00:450TTTTSTHISTORY
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, 10240OTPHYSICAL 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, 
10240ATPRIMARY
Diet pills, R/O Tricyclic antidepressives
SECONDARY
Obesity10240PTD/C diet pills, increase exercise, 10240LTCBC -
Lytes -
Serum hCG -
PAP pending
GC pending
Chlamydia -
Guiac - x 3
LFTUs  -
Thyroid panel -
LH/FSH -
PT/PTT -10240GIRTET2475526255/30/94 3:45 pm4755262520011F5/30/94 3:45 pm00:450TTTTSTSensation 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 weeks10240OTPHYSICAL 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 blood10240ATPRIMARY
Orthostatic Hypotension
SECONDARY
Antyhypertensive therapy10240PT10240LTCBC -
Lytes -
MRI -10240GIRTTylenol, 200mg2 capsulesbefore mealsDailyfor 18 days30 capsules2 refillsNo SubstitutionMND14LC