VISIT REASON: Follow up of (1)________. The patient was recently seen in the emergency room on 05/06 and was placed on (2)________ and prednisone because of right facial shingles. She still continues to have right facial pain with tenderness over the ear but no difficulty in hearing. The patient also complains of tenderness on the right side of the face, lip, and the right side of the neck. The
patient occasionally gets chest discomfort and shortness of breath on (3)________. Currently she is not on any medication, but she does have a history of gastroesophageal (4)________ disease currently controlled with medication..
PHYSICAL EXAMINATION: Vital signs are stable. All systems are within normal limits.
IMPRESSION AND PLAN:
1. Follow up of shingles, currently stable. The patient has (5)________ (6)________ but do not want to pursue any medications at present. The patient was reassured that she will have pain possibly for 6 months to 2 years and will possibly consider (7)________ if the pain gets worse. Will follow up in 6 weeks for that.
2. Chest discomfort. An (8)________ was done today which showed normal sinus rhythm without any ST-T-wave changes.
3. Gastroesophageal reflux disease. Will continue on an antireflux diet and Pepcid AC p.r.n. Will follow up.
1. shingles
2. Ceclor
3. exertion
4. reflux
5. postherpetic
6. neuralgia
7. Neurontin
8. EKG
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