Caleb Zimmerman
 
 
 From: DAVID GOLDMAN 
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 Page: 22 of 72 
 Jul 30, 2015 4:33 PM 
 Caleb Zimmerman 
 Visit Note - May 26, 2022 
 PMS ID: 
 Sex: 
 DOB: 
 Female 
 Aug 31, 1986 
 093158 
 Medications 
 Chief Complaint: F/U Keratoconjunctivitis Sicca OU evaluated on May 26, 2014 
 Reviewed February 2021 
 OPHTHALMIC MEDICATIONS 
 erythromycin 5 mg/gram(0.5 %) 
 ointment OU 
 HPI: This is a 66 year old female who is presenting as an emergency with pain OS. She is following up for 
 FML Forte 0.25% drops,suspension 
 Keratoconjunctivitis Sicca OU. 
 OU 
 She was seen on February 23, 2021, at which time the 
 patient was counseled, she was treated with OTC Regimen Dry Eye, 
 NON OPHTHALMIC MEDICATIONS 
 amlodipine 5 mg Oral tablet 
 The following treatment regimen was given: 
 atorvastatin 20 mg Oral tablet 
 Continue the following treatment(s): 
 bupropion HCI 150 mg Oral tablet 
 1. Increase Erythromycin ou Qhs 1st two weeks of every month 
 extended release 24 hr 
 2. Discussed Restasis, Xiidra, or Cequa if needed as well as plugs with low Schirmers 
 citalopram 40 mg Oral tablet 
 3. Artificial tears Q2hr as needed 
 diphenoxylate-atropine 2.5-0.025 mg 
 Oral tablet 
 4. Warm compresses with lid hygiene BID 
 hydrochlorothiazide 25 mg Oral 
 5. F/u with Dr. Laird as arranged 
 tablet 
 6. Call if symptoms persist 
 lorazepam 1 mg Oral tablet 
 7. F/u with MSM 6 months to check IOP and lids or sooner PRN 
 losartan 100 mg Oral tablet 
 and the following items were planned: 
 mirtazapine 15 mg Oral tablet 
 sumatriptan succinate 100 mg Oral 
 Mark Milner (Primary Provider) (Bill Under) 
 David A. Goldman MD LLC 
 Page 1
 Suite B 
 Palm Beach Gardens, FL 33410
