
LTJG Sovum, Veneela
Physician
PATIENTS NAME: LT. Tzedek, Alariya
APPOINTMENT STARDATE: 100166
PURPOSE AND CONTEXT OF EVALUATION
Baseline Medical Assessment
CONCLUSION
Lt. Tzedek is phsyically able to carry out her duties within the fleet.
SUBJECTIVE FINDINGS
Lt. Tzedek was aware of her surroundings and conscious through the appointment.
OBJECTIVE FINDINGS
Review of Physiological Systems
Section | Status | Comment |
---|---|---|
HEENT | NAD | Responses normal. (or add your own comment) |
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. |
The Lieutenant has a few lingering injuries that while not life threatening or in jeopardy of preventing her from performing her duties, does warrant additional treatment.
PLAN OF CARE
The Patient has in the past sustained a bi lateral radius break and an ulna break. It does cause the patient discomfort at times, often hitting a pain threshold of five out of ten. To combat this, I am ordering the patient to report to the infirmary on days where pain levels hit it peak to dull it down.
50cc of analgesic was used in the course of the appointment
Patient further vocalized a concern of taking oral medication due to a previous host having an addiction of pills.
Avoid Orally prescribed medication.
LENGTH OF APPOINTMENT: # 1 hrs
END OF EVALUATION.