Adam Martinez

 
 2017-06-01 02:58 PM 
 TO:75062956136 FROM: 8542570401 
 Page: 61 
 1992-12-15, Account No: 74788 
 guidance, and coursening. SMUNING Relapse prevenuent DISCUSSED the importance 
 of a supportive environment and helped identify them.. 
 Follow Up 
 6 Months 
 History of Present Illness 
 LVEF Recordings: 
 Based on - CATH. Ejection Fraction Result (%) 35, Date 02/15/2018. 
 Electrocardiogram (ECG): 
 Examination 
 General Examination: 
 GENERAL APPEARANCE: in no acute distress, well developed, well nourished. 
 HEAD: normocephalic, atraumatic. 
 EYES: pupils equal, round, reactive to light and accommodation. 
 EARS: normal. 
 ORAL CAVITY: mucosa moist. 
 THROAT: clear. 
 NECK/THYROID: neck supple, full range of motion, no cervical 
 lymphadenopathy. 
 SKIN: no suspicious lesions, warm and dry. 
 HEART: no mumurs, regular rate and rhythm, S1, S2 normal. 
 LUNGS: clear to auscultation bilaterally. 
 ABDOMEN: normal, bowel sounds present, soft, nontender, nondistended 
 Extremities no clubbing, cyanosis, or edema. 
 NEUROLOGIC: nonfocal, motor strength normal upper and lower extremities, 
 sensory exam intact. 
 SIMONS, CHARLES 
 M61 
 DOS : 2016-04-04 
 DOB: 1992-12-15 
 Acct : C11920 
 PrimProv: Prada, Stefan, MD 
 Electronically signed by KACI DYMOND on 2019-01-17 at 04:40 PM EDT 
 Sign off status: Completed 
 To: 360 Ortho and Spine. Subject: Progress Notes, Fax#: 833-367-4968. SendDate: 2017-06-01 09:52:47. page 2/3 [-ufg2.4.1.12in]
