LT S'Slaask
Physician, DS13
PATIENT’S NAME: CMDR Barron-Stern, Jessica
APPOINTMENT STARDATE: 99443.9
PURPOSE AND CONTEXT OF EVALUATION
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Medical Routine Exam - Patient scheduled appointment coinciding with new assignment to starbase. Performed sequentially following unscheduled visit.
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Medical Incident - Patient arrived for prior to scheduled exam, accompanied by superior officer, reporting illness.
CONCLUSION
Patient’s acute symptoms attributable to first trimester pregnancy and situational anxiety. Patient is otherwise in good overall health. Treatment plan ordered as noted below. Deemed medically fit for duty without reservation.
SUBJECTIVE FINDINGS
Patient reported sudden onset dizziness, nausea, vomiting, chills, mood swings, and near-syncope. Occurred at rest without precipitating incident. Denies recent illness, trauma, extracorporeal encounter, other high-risk contact.
OBJECTIVE FINDINGS
Patient alert and oriented, speaking in full sentences, breathing without difficulty. Patient is vomiting. Cardiopulmonary function intact. Mild tachycardia, mildly increased cardiac inotropy. Neurological function intact. Psionic function intact. Vital signs WNL except as noted. Lab values abnormal.
Patient is pregnant. Gestational age estimated to be 10 weeks. CRL is 6.1 cm. Umbilical cord well-formed and intact. Fetal cardiac activity present and unremarkable.
▲ bCG
▲ Cholesterol
▲ Creatinine
▲ Progesterone
▼ Protein (total)
▼ Psilosynine
▼ Uric Acid
▼ Urea nitrogen
(values WNL omitted)
PLAN OF CARE
After being informed of her pregnancy, patient suffered an anxiety attack and subsequent brief witnessed syncopal episode. Patient regained consciousness without treatment. Recommend self-monitoring for further anxiety symptoms. Will provide referral to Counseling if persistent.
Patient has been provided replicator-synthesizable prescriptions for an antiemetic and a mild analgesic for PRN symptom relief. Referral entered for patient to Mammalian Obstetrics.
LENGTH OF APPOINTMENT: 2 hrs
END OF EVALUATION.