Shannon Perry
 
 
 From: DAVID GOLDMAN 
 Fax: 
 To: 
 Fax: (610) 354-8946 
 Page: 4 of 72 
 13 June 2020 4:33 PM 
 Shannon Perry 
 Visit Note - 17 March 2015 
 PMS ID: 
 Sex: 
 DOB: 
 MRN: 
 438-5647467272 
 Female 
 20 June 2003 
 016659 
 Medications 
 OPHTHALMIC MEDICATIONS 
 Chief Complaint: Eye Irritation 
 NONE 
 extended release 24 hr 
 citalopram 40 mg Oral tablet 
 diphenoxylate-atropine 2.5-0.025 mg 
 Pt has not been using drops currently. 
 Oral - tablet 
 hydrochiorothiazide 25 mg Oral 
 Pt tried Restasis 2015, did not help (pt has no idea how long she used it for) 
 tablet 
 lorazepam 1 mg Oral tablet 
 No asthma, yes some seasonal allergies. 
 losartan 100 mg Oral tablet 
 S/P LASIK OU 2010 
 mirtazapine 15 mg Oral tablet 
 Pt has not tried plugs. 
 sumatriptan succinate 100 mg Oral 
 Pt states last eye exam 03/2019 
 tablet 
 temazepam 15 mg Oral capsule 
 Aimovig Autoinjector 70 mg/mL 
 On further history taking, pt has no grittiness, no burning, no irritation but pt's only complaints are a film over the vision 
 Subcutaneous auto-injector 
 OU that fluctuates (not like a floater or black spider web) and crusting (seldom) upon awakening 
 Last dilated exam over 1 year ago 
 Ocular History 
 Obtained and Reviewed December 
 28, 2020. 
 Allergic conjunctivitis 
 Tear film insufficiency 
 Eye Exam 
 Wears glasses 
 Vision 
 Distance Test Type: Snellen Chart 
 Mark Milner (Primary Provider) (Bill Under) 
 David A. Goldman MD LLC 
 Page 1 
 (561) 630-7120 Work 
 3502 Kyoto Gardens Dr 
 (561) 630-7122 Fax 
 Suite B 
 Palm Beach Gardens, FL 33410
