Though all Hgb was noted as being acceptable but lower than normal for this species in an oxygen rich environment, and subject’s copper levels were on the lower end of the acceptable range for this species. This has been indicated that the subject is at elevated risk of anemia. (1)
OBJECTIVE FINDINGS
All screens passed.
Subject is in good health.
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.
PLAN OF CARE
Optional: Recommended copper supplement PRN PO or change to copper rich dietary plan. Infusion PRN IV but only if levels drop lower than acceptable. (2)
Notes:
(1) as per SFSMD 2422 ed. via Tricorder
(2) as per SFSMD VIII.0202a Para 13.
LENGTH OF APPOINTMENT: 1 hr END OF EVALUATION.
OOC
Worked with player to set this up. We wanted the RP to be fleshed-out.
Patient has no significant illness or injury and is rated fit for duty.
SUBJECTIVE FINDINGS
Patient reports overall good health. Mild sleep deprivation due to adjustment to new shift schedules but no significant impairment to duties. No other concerns were expressed.
OBJECTIVE FINDINGS
Routine medical examination was conducted. Notable findings include:
Scarring on the left ear from a childhood injury, no reported hearing impairment.
Slight leg length discrepancy (right leg marginally longer than left) – previously treated, no current functional limitations.
History of a previously broken tail – fully healed with no residual effects.
All vital signs within normal limits. No abnormalities were detected on the scan.
Review of Physiological Systems
Section
Status
Comment
HEENT
NAD
Mild scarring on left ear, no functional impairment.
Respiration
CTA
Responses normal.
Cardiovascular
NAD
Pulse and pressure within normal limits.
Abdominal
NAD
NBS, all scans clear.
Extremities
NAD
Slight leg length discrepancy, no reported difficulties.
Neurological
NAD
Patient was coherent, coordinated and responsive WNL.
No medical intervention is required at this time. Patient was advised to report any worsening musculoskeletal issues due to leg length discrepancy, especially if it worsens.
Patient is to report to medical if sleep deprivation continues.
Patient is of sound health and deemed fit for full active duty.
SUBJECTIVE FINDINGS
Patient reports pain at site of amputation LT BK at beginning of shift which goes away. No other concerns regarding their health.
OBJECTIVE FINDINGS
Patient has prior injuries. Amputation LT BK. Patient uses mechanical prosthesis, which provides sufficient mobility for ship board and flight duties.
Recommended patient find destress method as labs and a neuro show heightened stress levels.
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. EXCL Amp LT BK
Neurological
NAD
Patient was coherent, coordinated and responsive WNL.
Patient is currently on restricted duty. I am so far satisfied that his physical injuries will no longer be of concern once he returns to full duty, though have concerns in regards to the source of said injuries.
SUBJECTIVE FINDINGS
Patient complained of ‘phantom pains’ regarding the recent inury he’d suffered while off duty, though had no other complains or concerns.
OBJECTIVE FINDINGS
Patient claims to have recently been involved in an accident while on leave, where a conduit exploded in close proximity to him. The medical staff aboard the transport in question apparently saw to his inuries. This only partially matches up with the physical damage present.
Patient’s neurological condition remains within expected parameters.
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
Scarring and burns localised around upper left arm and chest.
Neurological
NAD
Hightened activity around emotional and memory centers, though patient was coherent, coordinated and responsive WNL.
LENGTH OF APPOINTMENT: # ~1.5 hrs END OF EVALUATION.