HISTORY AND PHYSICAL EXAMINATION
An 11-7/12-year-old female who states that she has heard a noise in her right ear off and on for the past few weeks. She has had no fever, no rhinorrhea, no cough, no vomiting, no diarrhea, no dizziness, no headache. She has suffered no loss of consciousness. She takes no medications at the present time.
PAST MEDICAL HISTORY
No hospitalizations. No operations. No allergies. Immunizations are current.
PHYSICAL EXAMINATION
GENERAL: Alert, well-nourished, well-developed female in no acute distress.
SKIN: Clear.
HEENT: Eyes: Sclerae white. Conjunctivae clear. Fundi within normal limits. Ears, nose, throat entirely within normal limits.
NECK: Supple. No adenopathy.
LUNGS: Clear.
HEART: Regular rate and rhythm without murmurs.
ABDOMEN: Soft, nontender. No masses or hepatosplenomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
GENITALIA: Normal Tanner stage 2 female external genitalia.
NEUROLOGIC: Tone within normal limits. Deep tendon reflexes 2+. Finger-to-nose intact without tremor. Audiometry is within normal limits.
IMPRESSION
Questionable tinnitus — etiology unclear.
PLAN
1. Symptomatic care.
2. Return to clinic if tinnitus does not resolve.
3. Hemoglobin.
4. Urinalysis.
5. TB tine.
FOOTNOTE
Lines 18-31. The subheadings were added for clarity.
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