7/27/2019 Zimmerman Trial: 2012 Feb 27 Medical Report

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03/09/2012 15:57 To: attn: InvestigatorSi. Attn: From: Altamonte Family Practice Fax.8304300, Phone:4073326366 Page 1 of 4Fax

Date: 03/09/20 12Recipient:Fax Number: 4076885071Sender: Zelaya, AshleyNumber of pages mck1ding Cover: 4Comments:

Altamonte Family Practice249 Maittand Ave Ste 1000

Altamonte Springs, FL 32701Phone:407-332-6366

fax: 407-830-4300

Prtv3cy ~ : ThiS menage -s intended ror the uso or the indMctual or enllty to whi:h fr is &ddte$sc:d ~ ~ n d ma.y con,., n tnrotn"\lfUonthat is p r i v i ~ , OHII'Idc:ntial or aem,x fram disdos:ute under p p l k : ~ b l e tedatjtl or 13w. U the f ~ d e t d tlti5 l'neSSIIOf! is not theIntended rcdpk:tlt. or the emPIOVOO d bOCnt rcsponslb1c for dcwcring WI ft"'CSJOOO to the inmnded t ~ l ~ yau arc horebr notiAc!d thotenv ~ t l o n r distriburion. or topoylng -o( lhls communication is stnctly f)rohlbited. Uyou have n:cciYc:d th\s cammunatloft in cnor, p & u ~notffv us l m m c d i D ~ bv telephone and return the ori9fMI mc::saoc to us at the ~ b c > v c ~ d d t c s s via u.s. oost41 $C'l"'ricc..lis WonmtUon ha s been disciQsc:d to rou from records protected vndet F o d e r ~ l c.onttdcntlltlitf rules (42 CFR. patt lfl). The fccktral ru1es

P r o h l ~ ,.ou making any further cfoc:lo:surc of this infomudion wftmxn the cxptCSS written eonscnt o f t ~ ~ r s o n to who it C)C!tt'ains or osothenvlse pennltte.d brt -12 CIIR., port n. 1"ho OCMntl tuthoritatn for the: tcktosc ofmedica1 or other information is not sufficient for Ehi'purpos. 'The fedcntt rules I'CS'trkt onv " ~ of thC' nfonnotion to c r i m i n ~ l 1 y t n v t s t ~ l c Of PtOSOCute any ~ l ( o h o l Of druo tbus.t P4tJcnt.

7/27/2019 Zimmerman Trial: 2012 Feb 27 Medical Report

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. 03/09/2012 15:57 To: attn: InvestigatorS. Attn: From: Altamonte Family Practice Fa-8304300, Phone:4073326366 Page 2 of 4

Altamonte Family Practice249 Maitland Ave Ste 1oooAltamonte Springs, FL 32701Phone: 407-332-6366Fax: 407 8304300

Patient: GEORGE M ZIMMERMAN, 28 year old Male, Race: While, SSN: XXX-XX-9331, DOB: 10/05/1983Encounter Date: 02127/2012 11:02 amEncounter Closed Date: 03/09/2012 03:37pm

lication

Plan:Decision Making Process:.. Follow up: previously scheduled fo r routine follow up Call if any problems before the next visit. 512012 with LF.. MEDS: Continue present tx. Risks, benefits & side effects were discussed. Add Lodine BID PAN for Sl Joint pain. Usecautiously given dx of IBS.; Pl Education {physician): Discussed Ox and Tx plan, symptomatic tx and reassurance.

1. Scalp Lacerations: No sutures needed given well-approximated skin margins. Continue to clean with soap and waterdally. We discussed the red flag symptoms that would warrant Imaging given the type of assault he sustained. Given thetype of trauma, we discussed that it Is imperative he be seen with his Psychologist for evaluation.2. Broken N o s e ~ W e discussed that it is likely broken, but does not appear to have septal devialion. The swelling andblack e.yes are typical of this injury. I recommended that he be evaluated by ENT but he refused.3. Sl Joint pain: Likely due to the assault. May use ice/heat, massage: and Lodine as needed, Use cauliously given h/oIBS.4. Tonsillar Stones: May use lemon drops to promote salivation and remove the stones as they appear to prevent furtherIssues. May be seen by ENT for further eval. Specialty Referral: ENT and psychological counseling eval. Patient refused to be seen by ENT at this time and the riskswere discussed.

Chief Complaint:.....Acute com plaint. History of Present Illness:Presents today complaining of Nasal pain. .Patient was involved in an altercation on 2/26. During the altercation he was

assaulted, punched in the face, and shoved to the ground where his head was hit into the pavement multipletimes. During the altercation, he had a weapon as he is authorized to carry a firearm and he fired at the attacker, killinghim. He was evaluated by EMS and slates his lacerations were cleaned. He was told that he had a broken nose anddenies being taken to the hospital. He then returned to work and was told he needed a pollee report and medicalclearance to return to work. He denies HA, change in VA, slurred speecl:l, dizziness, or gait abnormality. Admits tooccasional nausea when thinking about the violence last night, but denies abdominal pain. Also complaining of left Sl jointtenderness since the event. Denies numbness/tingling or incontinence.

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7/27/2019 Zimmerman Trial: 2012 Feb 27 Medical Report

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03/09/2012 15:57 To: attn: Investigator Si. Attn: From: Altamonte Family Practice Fax.8304300, Phone:4073326366 Page 3 of 4

Altamonte Family Practice249 Mattiand Ave Ste 1000Altamonte Springs, FL 32701Phone: 407332-6366Fax: 4078304300

Patient: GEORGE M ZIMMERMAN, 28 year old Male, Race: While, SSN: XXX-XX-9331, DOB: 10/05/1983Encounter Date: 0212712012 11:02 am. Encounter Closed Date: 03/09/2012 03:37pm

Also concerned to r lonsillar stones that have been present tor many years. States these become tender and bothersome.OV dominated by counseling/coordination of care lasting> 25 minutes. All data reviewed with the pt. FlU care, referralsand Ax's have been arranged.Notes: P{t Is here fo r a return note for work. Pt was in fight on 2/26/12, pt was punched In nose and has 2 laceration Inthe back of head. 911 was called and EMT said pts nose was broken. DVActive MedicationsDate !Drug & Dosage Qty ISIG Refil l Note02127/2012 Iodine 400 mg tablet 60 1 tablet PO BID Oprn pain02i13/2012 ladderall 20 mg tablet 60 1 1ablet PO BID OWritten Rx GivenP1123t2012 ,emazepam 30 mg capsule 90 1 capsule (hard, soft, 0

~ t c . ) P O HSP1123/2012 ~ m eprazole dr 40 mg 30 1 capsule,delayed release 3?RN!Capsule lienteric coated) PO Daily12/29/2011 ~ l b r a x 90 1 capsule (hard, soft, 3leto.) PO TIDAc I M dlve e ca t ons- P E I tle- x s ng:Drug & Dosage $t Gpvs alucosamine chondroitin tb 1 tablet PO Dailymultiple vitamin tablet 1 tablet PO Dailyomeprazole dr 40 m g capsule 1 capsute,delaved release (enteric coated) PO DaUvemazepam 30 m g capsule 1 capsule (hard, soft, etc.) PO HS

Review of Systems:Constitutional Symptoms: Denies fevers and/or chills.Eyes: Denies loss and blurring of vision, diplopia.Ear, Nose, Mouth, Throat: Admits nose pain. Denies hearing loss, tinnitus.Cardiovascular: Denies palpilalions, chest pain/pressure.

R e s p l r a t ~ r y : Denies shortness of breath.Gastrointestinal: Denies abdominal paint nausea and/or vomiting.Integumentary: Admits- (Scalp lacerations).

Note

PAN

Neurological: Admits head trauma. Denies tingling, numbness, weakness, headache, dizziness, speech dirricully, gaildisturbance, loss of consciousness.Psychiatric: Admits stress. Denies suicidal thoughts or attempts.Physical Exam:

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03/09/2012 15:57 To: attn: InvestigatorS. Attn: From: Altamonte Family Practice Fax.304300, Phone:4073326366 Page'\ of 4

Altamonte Family Practice249 Maitland Av e Ste 1oooAltamonte Springs, FL 32701Phone: 407332-6366Fax: 407830-4300

Patient: GEORGE M ZIMMERMAN, 28 year old Male, Race: White, SSN: XXX-XX-9331, DOB: 10/05/1983Encounter Date: 02/2712012 11:02 amEncounter Closed Date: 03/09/2012 03:37pm

General Appearance: No acute distress. He is obese. He is alert & oriented and appears his stated age.Head: Normocephalic, atraumatic. The face is symmetric. Two scalp lacerations to occiput .. 2cm & O.Scmrespectively. Skin edges approximated well.Eyes: PERRLA: EOMI, conjunctiva and sclerae clear. BIL black eyes.Ears, Nose, Mouth, Throat: Bruising noted to nasolabial folds BIL with swelling. No evidence of septal deviation onvisual inspection. No bleeding noted in nares. No hemotympanum to B/L ears. No evidence ot tonsillar stones.Chest: Lungs: Clear to auscultation. Breathing is normal.Cardiovascular: Heart is RR R with normal S1 and S2. No murmurs or eotopy Musculoskeletal: Gall is normal. Lumbar spine reveals normal lumbar lordosiS. There Is tender left Sl area. ROM normalror age and body habitus. Motor examination reveals muscle strength 5/5 bilateral and symmetrical in all 4 extremities.Neurological: Neuro: No focal neurological deficits appreciated. Cranial nerves II - XII are grossly intact.Psychiatric: Mood is appropriate. Affect is appropriate.This char& has been electronically signed using individually secured passwords.Attending Physician Assistant: Llndzee E. Folgate, PA-C

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