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Younes v. Nolan1/19/2005
unes noted a first visit on January 23, 1998 and also noted that a problem list was created, but did not put any of the interim dates between January 23, 1998 and April 16, 1998 on the problem list because he said the problem list did not change. (Tr. 9/11/02 at 52.) There were no visits between October of 1998 and April of 1999. (Tr. 9/11/02 at 60.) Although the notes for April 16, 1999 showed that the nurse wrote "cervical pain," Dr. Younes himself did not document anything with respect to the neck on that April visit. (Tr. 9/11/02 at 61.) There was a span from October 1998 through April 1999 (six months) in which Dr. Younes did not do a detailed exam, as he testified that if he had, he would have documented it. (Tr. 9/11/02 at 65.)
On the issue of cervical pain, there was no reference to anything addressing the subject of cervical pain in Dr. Younes' notes. (Tr. 9/11/02 at 65-67.) Dr. Younes admitted that you could not tell whether Patient A had a complaint of pain that day or if it was a complaint of past cervical pain. (Tr. 9/11/02 at 67.) He stated that it could have meant yesterday, last week or last month. (Tr. 9/11/02 at 68.) Dr. Younes testified that Patient A's blood pressure has been going up from 140 on October 29, 1998 to 160 on April 16, 1999. (Tr. 9/11/02 at 75.) He testified that on June 3, 1999 the blood pressure was 174 over 82 (Tr. 9/11/02 at 76), and that complaints to the nurse showed pain of the head radiating down the right face and neck. (Tr. 9/11/02 at 77.)
The cross-examination of Dr. Younes, as well as the direct examination of Dr. Younes, was continued to June 29, 2004. Dr. Younes admitted that he did not document whether or not the patient had cervical pain at the time of the June 3, 1999 visit. (Tr. 6/29/04 at 7.) With respect to negative pertinent findings, he said that he didn't document negative findings if at the time it was not a complaint to him. (Tr. 6/29/04 at 7-8.) With regard to the June 3, 1999 visit, Dr. Younes stated that he discussed with Patient A the type of headache she had, its severity, and if there were any other symptoms associated with it, but that he did not document any of this information. (Tr. 6/29/04 at 23.) He stated that usually he would touch the face of a person with headaches, but admitted that there was no indication in his records that he touched the face of Patient A on that particular day. (Tr. 6/29/04 at 24.) He agreed that looking at his records there was nothing to show that he examined her head outside of the evaluation at the end relating to the question of stress associated with a headache. (Tr. 6/29/04 at 26.) Dr. Younes also agreed that that was an assessment rather than an evaluation. (Tr. 6/29/04 at 26.) Dr. Younes further conceded that there was nothing in the records to show that an examination of the head, the face or the neck was done. (Tr. 6/29/04 at 26-27.) He said that he did not discuss with Patient A any problem regarding a muscle in her neck. (Tr. 6/29/04 at 27.) He also testified that Patient A never complained about a lump on the side of her neck. (Tr. 6/29/04 at 28.) When asked about palpating the side of her neck to look for a lump on June 3, 1999, he stated that when you do an examination, you do touch the posterior aspect of the neck to see if there is any tension headache. (Tr. 6/29/04 at 28.) However, Appellant admitted that his examination was restricted in the back and didn't come forward towards the side at all. (Tr. 6/29/04 at 29.) Dr. Younes stated that he never touched anything under the jaw. (Tr. 6/29/04 at 30.) With respect to negative findings concerning lymph glands and lymph nodes, Appellant admitted that there was nothing in his records. (Tr. 6/29/04 at 30-31.) Appellant stated that he did not re
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