Benign Positional Vertigo Chart Note Sample Report
DATE OF SERVICE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman with a significant past medical history of prostate cancer and hairy cell leukemia. He comes in today for a question of vertigo. He had an episode yesterday. He woke up, went to get out of bed, and felt the room spinning. He had some nausea associated with it. He lay back down. The room spinning and nausea quickly resolved.
He then attempted to get up out of bed slowly. This time, he was able to without difficulty. He does describe his symptoms as the room spinning. He also describes some associated nausea. These symptoms are brief, lasting only a couple of seconds when he changes his head position from lying to sitting or standing. He does think that he may have had vertigo a couple of years ago associated with a viral ear infection.
He is feeling well today. No fever or chills. No earache. No nasal congestion. No other upper respiratory symptoms. No changes in his hearing. No changes in his vision. No diplopia. No dysarthria. The patient is otherwise feeling well.
PAST MEDICAL HISTORY:
1. Hairy cell leukemia.
2. Prostate cancer with partial prostatectomy.
3. Nephrolithiasis.
4. Vertebral fracture.
5. Cardiac arrest secondary to cocaine with ventricular fibrillation in the remote past.
6. Asbestosis.
7. Diverticulosis.
MEDICATIONS: None.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: On examination, the patient is a very pleasant gentleman in no acute distress. He is afebrile. Temperature is 97.4. He is not orthostatic. Blood pressure is 120/66 seated, 112/62 supine, and 114/62 standing; pulse 72 in all positions. HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Sclerae are anicteric. TMs are benign without any erythema or perforation. Bony landmarks are well visualized. Nasal and oral mucosa pink and moist. Neck is supple without adenopathy. Lungs are clear to auscultation bilaterally. Heart reveals normal S1, S2. Extremities are without edema. Gait is normal. Neurologic: Nonfocal. We are able to reproduce the patient’s symptoms with moving him from a supine to seated position. He had about 3 seconds of room spinning with mild nausea. His symptoms resolved without intervention.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old gentleman who presents today with benign positional vertigo. He notes that his symptoms have improved since yesterday. He will monitor his symptoms and follow up if they persist or worsen.
