🔗 Linked Evidence
Dr._Samad_May_27 — p.1
📄 Dr. Samad May 27 | p.1
📄 Dr. Samad May 27 | p.1
📝 Extracted Text (OCR)
5/28/2026, 7:30 AM PDT TO: +160452272@6 FROM: 16045219323 PAGE 1/2 DR. IDRIS SAMAD, MD, FRCSC Otolaryngology - Head and Neck Surgery MSP: 44406 Basement 4B-625 Fifth Ave New Westminster, BC, VM-1X4 P: 604-524-4931 F: 604-521-9323 Dr. Gbogboade Adeboyega Ademiluyi Mr. HOLAND, Mark 311-318 anges street New Westminster, BC, CAN MSP: 68199 420 Columbia St New Westminster, BC, V3L-1B1 : . . 699. date of birth : September 04, 1978 age: 47 P: (604) 522-2206 F: 604-522-7206 home phone : (236) 994-3376 sex: Male work phone : other phone : PHN : 9128 549 738 May 27, 2026 Dear Dr Ademiluyi, Thank you for referring this 47-year-old gentleman who is here today for ears. He has provided some reference materials to review prior to consultation. Subjective: - Reports left ear pain since 01/23/2026, following exposure to industrial server noise at work. The pain was initially severe (9-10/10) and is now rated 2-5/10. The right ear pain has resolved. - Associated symptoms include pulsatile tinnitus in both ears, worse on the right, and a history of migraines, which are typically well-managed but were exacerbated by the ear pain. - Past medical history includes chronic spontaneous urticaria, managed with bilastine, and a concussion 20 years ago. - Medications: bilastine daily, ttazodone, quetiapine, risperidone, sertraline, coenzyme Q for migraines. - Allergies: No known allergies. - Social history: Quit smoking and drinking. Works for SkyTrain. - Reports significant sleep disruption, with body twitching every 30 seconds, requiring trazodone and quetiapine for sleep. Has not seen a sleep medicine specialist. - Hearing testing performed elsewhere was normal. Head and Neck Examination: - Inspection of the head and neck reveals no significant abnormalities. Voice is normal; Speech is normal. - Palpation of the neck is soft and non-tender, without adenopathy. Mild tenderness noted on palpation of the left temporomandibular joint/masseter muscle. A click was noted on wide opening of the jaw. - Ears were microscopically normal bilaterally. - Oral cavity examination reveals signs of bruxism. Tongue movement is full in all directions. - Anterior rhinoscopy demonstrates a midline nasal septum with normal nasal mucosa bilaterally. Audiometry and case files reviewed. Impression: - Left ear pain, likely secondary to masseter muscle inflammation and temporomandibular joint dysfunction. - Loud noise exposure from work may have been an exacerbating factor causing muscle tension related issues. - No apparent otologic pathology. - Normal hearing without significant concern. Plan: - The patient is quite distressed by his symptoms and continues to be bothered by left sided otalgia. Consultation Report PLEXIA Electronic Medical Systems Inc. Page 1 of 2 www.plexia.ca