CLINIC NOTE

PATIENT NAME:
MEDICAL RECORD NO.:
PAGE 1

NAME: Seguin, Cara Joy B. DATE: July 25, 2019

SECTION: HSMT 12-3 PETA No. 4.1

PATIENT NAME: Mr. Carl Ewing

MEDICAL RECORD NO.: 5477211
DATE OF SERVICE: July 25, 2019
ATTENDING PHYSICIAN: Dr. Sabrina Scott

CLINIC NOTE

REASON FOR VISIT: Mr. Ewing is a 1 55 -year-old 2. gentleman seen in our clinic
for the first time to establish 3. primary care.

HISTORY OF 4. PERSON’S/PATIENT/S ILLNESS: First, his most 5. troubles and problem

has been his right 6. sciatica , a problem for 7. 12 years. It 8. waxes and 9. wanes, apparently in
relation to how much time he spends on 10. each national travel sitting in a plane. He occasionally
requires 11. vicodin to relieve the pain.

He also continues to have some “spasms” in the left side of the neck and 12. trapezius area for
which he takes 13. Neurontin 600 mg 2-3 times per day.

Third, he has14. depression and this has worsened lately. He made a suicide attempt 8-9 months
ago. He currently is on 15. Lexapro 40 mg daily which he states has proved to be very beneficial.
He sees Dr. Scott Steinberg. He is in a very bad, nearly intolerable, second marriage situation to an
alcoholic, abusive wife. That relationship is anticipated to end in divorce in the near future.

REVIEW OF 16. SYSTEM : He generally feels 17. healthy . For the last 6 weeks, he has
noted a headache a couple of times per week, usually in the glabellar area, usually in the evening.
He treats it with Extra-Strength 18. Tylenol . He recently has noticed some mild 19. sunisitis in
the right ear. He has no 20. cardiopulomnary symptoms. He has no trouble passing his 21. stool
since surgery for hemorrhoids a number of years ago. He has no 22. genituorinary or 23.
muscoloskeletal system .

SOCIAL HISTORY: He continues to enjoy his career as a stockbroker. He travels extensively

internationally. No 24. tobacco . Minimal 25. alcohol . No exercise.

FAMILY HISTORY: His father and two paternal uncles have had 26. prostate cancer. His father,
age 75, is currently being treated. His mother is an alcoholic. His two brothers enjoy good health. A
daughter has trouble with 27. depression and has made a suicide attempt. A son has a psychiatric
illness.

MEDICATIONS: In addition to Lexapro, he takes 28. Candin 10 mg nightly, Allegra 100 mg

daily, Nasonex 2 times per day, Prilosec as needed, Extra-Strength Tylenol 3 at bedtime, saw
palmetto, and fish oil concentrate.
CLINIC NOTE
PATIENT NAME:
MEDICAL RECORD NO.:
PAGE 2

ALLERGIES: No known drug 29. alergate.

PHYSICAL EXAMINATION: On physical examination, his blood pressure was 30. 125/75 , pulse
31. 72 , height 32. 5 feet 10 inches , and weight 33. 220 pounds. He appears healthy but a bit
depressed and modestly 34. overweight . He has no significant cutaneous abnormalities. HEENT is
unremarkable. His thyroid and carotids are normal. He has no adenopathy. His chest, heart, and
abdomen are normal. Genitalia are unremarkable. His prostate is normal. Peripheral pulses are
readily palpable. Vibratory sensation is intact. Straight-leg raising equivocally positive at 35. 60
degrees on the right. Limited range of motion of the neck and shoulder girdle. Reflexes are all easily
elicitable and symmetric.

ASSESSMENT:
1. 36. Good at general health.
2. 37. Depression , on Lexapro.
3. 38. Degenerative disc disease, lumbar spine, with right sciatica.
4. 39. Allergic rhinitis, currently doing well.
5. Neck/trapezius spasm, unclear etiology.
6. 40. Family history of prostate cancer, depression, and alcoholism.

PLAN: He will have an EKG and blood drawn for chemistries, CBC, LFTs, and a lipid profile,
which we will review with him later in the day.

Cara Joy B. Seguin, MD

SS/ cse
DD: July 24, 2019
DT: July 25, 2019