ENS Gha'Kahrr
Medical Officer
PATIENT’S NAME:
CMDR Ruke Warner
APPOINTMENT STARDATE:
99454
PURPOSE AND CONTEXT OF EVALUATION
Baseline Medical Assessment
CONCLUSION
Patient is within acceptable health standards. Fit for full duty with exceptions.
SUBJECTIVE FINDINGS
The patient was initially dishonest about their physical state, however during the examination the patient stated they are having significant trouble maintaining proper sleep and has frequently awoke at nights as a result of nightmares related to what I suspect is a moderate case of Post Traumatic Stress Disorder from a previous posting being damaged and/or destroyed. This has been causing constant headaches which both this practitioner and the patient agree is detrimental to long term health and productivity.
This one as prescribed medication to assist with sleeping as a short term fix, however it was strongly recommended to the patient to schedule an appointment with the station counseling services.
OBJECTIVE FINDINGS
Bio scans support the patient’s claim of headaches due to lack of sleep. Scans also detecting the swelling of muscles along the patient’s right shoulder as a result of strenuous physical activity, which the patient has neglected to mention. The swelling was treated.
Patient as been advised that lying to or hiding details from medical practitioners is counter-productive to the patient’s on-going health.
PLAN OF CARE
Patient is prescribed a sleeping aid to assist with sleep loss. Patient has been advised to seeking counseling services.
Review of Physiological Systems
| Section | Status | Comment |
|---|---|---|
| HEENT | NAD | Responses normal. |
| Respiration | CTA | Responses normal. |
| Cardiovascular | NAD | Pulse and pressure within normal limits. |
| Abdominal | NAD | NBS, all scans clear. |
| Extremities | NAD | Responses normal. |
| Neurological | NAD | Patient was coherent, coordinated and responsive WNL. |
LENGTH OF APPOINTMENT: 2.1983hrs
END OF EVALUATION.