PATIENT
German Serrato
DOB
AGE
SEX
PRN
01/29/1985
35 yrs
Male
SG298088
FACILITY
Juan Carlos Rondon MD PA
T (954) 322-8985
F (954) 322-8981
3157 N University Drive
Suite 103
Hollywood, FL 33024
ENCOUNTER
NOTE TYPE
SEEN BY
DATE
AGE AT DOS
Not signed
SOAP Note
Carlos Pardo FNP-C,
DISPENSING
PRACTITIONER
09/25/2020
35 yrs
Chief complaint
Vertigo (Appt time: 4:00 PM) (Arrival time: 4:00 PM)
Vitals for this encounter
09/27/20
8:39 PM
Height
68.5 in
Weight
184.36 lb
Temperature
97.80 °F
Pulse
96 bpm
Respiratory rate
16 bpm
O2 Saturation
99 %
BMI
27.62
Blood pressure
115/72 mmHg
Diagnoses
Was diagnosis reconciliation completed?
Yes, reconciliation performed
Current
ACUITY
(H81.13) Benign paroxysmal vertigo, bilateral
Acute
(Z86.69) Personal history of other diseases of the nervous
system and sense organs
Chronic
Historical
ACUITY
START
STOP
START
STOP
No historical diagnoses
Drug Allergies
Was medication allergy reconciliation completed?
Yes, reconciliation performed
Active
SEVERITY/REACTIONS
ONSET
SEVERITY/REACTIONS
ONSET
No drug allergies recorded
Food Allergies
Active
No food allergies recorded
Environmental Allergies
g
Active
SEVERITY/REACTIONS
ONSET
No environmental allergies recorded
Medications
Was medication reconciliation completed?
Yes, reconciliation performed
Active
SIG
START/STOP
ASSOCIATED DX
SIG
START/STOP
ASSOCIATED DX
No active medications recorded
Historical
No historical medications recorded
Subjective
HPI:
This is an initial visit. Mr. Serrato comes to my o ce c/o dizziness, light headache, unbalance sensation x last 1 day. Symptoms are
similar to previous events (#3) that began on July 15th, 2018. Interventions the patient has tried have not provided any relief.
Additional information: He was diagnosed with Vertigo, treated by MD with rst generation oral antihistamine + head exercises.
Patient states that today he is feeling the same, despite of current treatment.
Objective
Physical Exam:
Constitutional: Normal - Well developed.
Eyes: Normal - Conjunctiva - Right: Normal, Left: Normal, Nystagmus
Ears: Normal - Inspection - Right: Normal, Left: Normal
Nose/Throat/Mouth: External nose - Normal
Neck: Inspection - Normal. Active painful ROM - (+) pain, tenderness, sti ness
Respiratory: Inspection - Normal. E ort - Normal.
Vascular: Normal - Capillary re ll - Less than 2 seconds
Abdomen: Inspection - Normal. Auscultation - Normal. Palpation - Normal
Musculoskeletal: Cervical, Thoracic, Lumbar Spine - Inspection: Normal. Range of motion: Normal. Strength UE:
Description - Upper extremity strength is normal: Bilateral. Strength LE: Description - Lower extremity strength is
normal: Bilateral.
Skin: Inspection: Normal
Neurological: Bilateral Nystagmus
Psychiatric: Normal. Orientation - Oriented to time, place, person & situation. Appropriate mood and a ect.
Assessment
Assessment:
1. Benign Paroxysmal Vertigo
2. History of Personal Vertigo
Diagnoses attached to this encounter:
(H81.13) Benign paroxysmal vertigo, bilateral
Acute
(Z86.69) Personal history of other diseases of the nervous system and sense organs
Plan
Plan:
1. Epley Maneuver
2. Meclizine 25 mg PO TID x 10 days
3. Follow up in 1 week or go to the nearest ER if symptoms persist or get worse.
Screenings/ Interventions/ Assessments
No screenings/interventions/assessments recorded.
0
