HISTORY: I saw Mrs. _______ for cardiological evaluation today. She is scheduled for right mastoid surgery on 04/23/09 at XXXXXX. During her evaluation at XXXXXXX, she was detected to have a cardiac murmur. She denies any exertional chest pain or undo shortness of breath. However, on account of unsteady gait, her activity is limited to household chores. She does manage to walk around the local mall at least twice a week. She admits to tinnitus in both ears. She also has a tendency to fall due to disequilibrium. She had a bad fall in September 2008 and sustained a fracture of her right wrist. She does not complain of headache, nausea, vomiting, or diplopia.
I get - Location, AS & S, Modifying Factors (Activity limited to household chores)
Anything else? Thanks!!! TGIF!!!!
Debby
I get - Location, AS & S, Modifying Factors (Activity limited to household chores)
Anything else? Thanks!!! TGIF!!!!
Debby