PATIENT’S NAME:
CMDR Akaela, Tala
APPOINTMENT STARDATE:
97647.1
PURPOSE AND CONTEXT OF EVALUATION
Medical Routine Exam
CMDR Akaela requested a Annual Medical Assessment.
CONCLUSION
Patient is in excellent health and meets all standards of physical fitness. They have passed all testing and evaluation necessary for medical personnel and have no significant medical conditions that bear review.
SUBJECTIVE FINDINGS
Patient believed to be in good health, stating that their visit was ‘For the records’ after having been gone for so long. Beyond that, patient did request a very low-dose hypo for minor eye strain and/or headaches, as they are currently stationed aboard a Romulan Vessel.
OBJECTIVE FINDINGS
Patient was in stable condition during and displayed no issues during scans; however, equipment did have to be temporarily adjusted to ensure that no false readouts would occur- something that had to be explained by the patient themselves, which can be rectified by adding it to their station Personnel File.
Patient has a form of microorganism that exists on their person that is part of a symbiotic bond with their body. While the patient had idle worries of the health of such organisms, scans did help relieve such worries; as all microorganisms were in as good of health as they were.
PLAN OF CARE
Patient was given a considered OTC Low-Dose Painkiller (2cc Morphenolog) that will last for a month or thereabout.
PATIENT’S NAME:
Captain Hen Dao Shin, MACO ( @Kelimnac )
APPOINTMENT STARDATE:
97652.5
PURPOSE AND CONTEXT OF EVALUATION
Baseline Medical Assessment
CONCLUSION
Patient was evaluated with multiple levels of medical scrutiny. No treatments were necessary, and all tests and assessments were passed. Additionally, no medical conditions were discovered during the evaluation. Patient is hereby medically cleared for duty.
SUBJECTIVE FINDINGS
The patient stated he was in good health, but expressed a willingness to ensure there was nothing he couldn’t openly feel. His only complaint was for eye strain, but he did not request a treatment for it, stating that rest should be sufficient. Upon being informed of his significant muscle strain following his recent training experience, he readily agreed to perform light duties for two weeks until his muscles have had time to rest. Overall, patient is medically cognizant of his limitations.
Notes on the patient’s own perception of their condition, including complaints, symptoms, and impressions.
OBJECTIVE FINDINGS
Patient reported in stable and alert condition, and remained so throughout the examination. All vital signs were normal, and scans indicated nothing significant to report. Scans did indicate two minor issues that were discussed - evidence of multiple bone fractures and strained muscles. The fractures did not leave any permanent damage, however, and appeared to be fully healed. The strained muscles were addressed separately, though no prescription was necessary.
PLAN OF CARE
Two weeks light duties to allow for proper physical rest and recovery following the patient’s recent training environment. Follow-up if issues remain after the light duty period.
PATIENT’S NAME: Sedai, Katriel E.
APPOINTMENT STARDATE: 97764.5
PURPOSE AND CONTEXT OF EVALUATION
Medical Fitness Evaluation - Ordered by Admiral Bishop following patient’s return from 15 days marooned on an unexplored planet.
CONCLUSION
Deemed fit for duty without reservation.
SUBJECTIVE FINDINGS
Patient reports no complaints. Patient denies chest pain, shortness of breath, headache, dizziness, and GI disturbances.
OBJECTIVE FINDINGS
Patient alert and oriented, speaking in full sentences, breathing without difficulty. No trauma noted. Cardiopulmonary function intact. Neurological function intact. Psionic function intact. Vital signs WNL attached. Lab values WNL attached.
PLAN OF CARE
Patient received prior treatment for minor injuries upon her return. No residual deficits noted. Antibiotic prophylaxis on file. No follow-up care required.
Medical Physical Evaluation following patient’s return from 15 days missing in action. Physical ordered by Admiral Bishop prior to patient RTD.
CONCLUSION
Standard and detailed medical scans in addition to a full lab workup revealed nothing that would hamper the patient in her duties. All wounds sustained during the patient’s time marooned are healing without issue, and no abnormal issues presented themselves in labwork or scans.
SUBJECTIVE FINDINGS
Patient expressed concern for her shoulder following her injury, and complained of soreness. However, the patient denied any pain and still had a full range of motion. Scans with tricorder and biobed indicated no issues with healing process. No other issues were reported.
OBJECTIVE FINDINGS
Tricorder and biobed scans revealed no cardiac, pulmonary, neurological, GI, skeletal, or muscular issues. Patient was alert and cognizant to her surroundings at all time. Vitals and labs samples were taken - all values normal.
PLAN OF CARE
Two weeks light duties after return to duty to avoid straining of prior injury. Recommendation of physical therapy to ensure any previously-damaged muscle can be nursed back to full strength. No additional medication prescribed.
CMDR Na’Toth is rated fit for duty without reservation.
SUBJECTIVE FINDINGS
The patient came in for the annual required physical exam.
OBJECTIVE FINDINGS
CMDR Na’Toth, despite her age and a considerable collection of former injuries, is in excellent physical health.
PLAN OF CARE
Though she is in good physical condition, like most entities who have reached the latter half of middle age, she could benefit from a nutritional supplement and, like many officers in command positions, a steadier supply of sleep. She has also expressed an interest in potentially regenerating her eye, so I provided information on the process involved.
Detailed scans via the use of Tricorder and Biobed revealed nothing of immediate concern that would hinder the patient from carrying out his duties as a Starfleet Officer
SUBJECTIVE FINDINGS
The patient expressed they were in good health and had no pressing concerns medically speaking oh their health
OBJECTIVE FINDINGS
Tricorder and biobed scans revealed no cardiac, pulmonary, neurological, GI, skeletal, or muscular issues. The patient was alert and cognizant of his surroundings at all times. Vitals and labs samples were taken - all values normal.
PLAN OF CARE
Though there is nothing of Immediate concern as noted, This officer advises the Captain to look into a physical therapist to assist in strengthing the muscles and bones around old wounds he had sustained. An hour of light stretches could help loosen up any problematic scar tissue developing beneath the skin.
LENGTH OF APPOINTMENT: # 1/2 hrs
END OF EVALUATION.
The Ensign is cleared for duty provided counseling does not find outstanding issues
SUBJECTIVE FINDINGS
The patient was open about certain habits they had partaken in during their younger years. Particularly drinking and the common lung damage associated with tobacco products that are prevalent on Earth.
OBJECTIVE FINDINGS
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
Advised the Ensign that it may be possible to surgically repair the damage to their lungs, but further research is required. Also advised the Ensign I would like to conduct a follow-up in ninety days (90) to check-in.
PATIENT’S NAME: LTJG John Fitzgerald Sandford. ( @Loxton )
APPOINTMENT STARDATE: 98020.3
PURPOSE AND CONTEXT OF EVALUATION
Medical Incident
CONCLUSION
The Lieutenant was remarkably drunk despite having been acting as a bartender for an off-duty social get together comprised of junior officers.
SUBJECTIVE FINDINGS
The lieutenant was close to suffering alcohol poisoning by the time we managed to get to sickbay. Slurred speech, motor movements of lower extremities failing punctuated by periods of high emotions and reflecting on his past. Biobed scans showed clear indications of alcohol saturation of the liver, lowered blood pressure, and raised pulse.
OBJECTIVE FINDINGS
The patient was immensely drunk, flushed, emotional, and prone to potentially falling down
PLAN OF CARE
I administered two cc’s of anti-intoxicant to the LT. It was not enough to instantly cure him of intoxication, however, it would be enough to at least alleviate the hangover. I recommend a follow-up and heavy consumption of nonalcoholic beverages. The patient is allowed to return to duty once he feels better.
LENGTH OF APPOINTMENT: # 0.5hrs
END OF EVALUATION.
The patients were alert and aware of their injuries and the circumstances surrounding their injuries
SUBJECTIVE FINDINGS
The patients all sustained lacerations and contusions to their upper torso with Captain Serah sustaining lacerations to their right hand running parallel to the metacarpal
OBJECTIVE FINDINGS
Patients were all relatively lucky their injuries were not more serious considering the circumstances. I am pleased to report that all three of the officers are cleared to return to duty
PLAN OF CARE
I want the officers that were injured to follow up with me in the next few days so I can check in on their progress, otherwise, they are free to return to duty
PATIENT’S NAME: Herra Assari Drowvani-Nimitz
APPOINTMENT STARDATE: 98204.6
PURPOSE AND CONTEXT OF EVALUATION
Medical Routine Exam
CONCLUSION
Miss Herra is in good health although there is a slight Vitamin C deficiency
SUBJECTIVE FINDINGS
Herra was attentive at all times and seemed to be a bit nervous at the start of the exam, however left in rather high spirits
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.
PLAN OF CARE
Suggested to Patient’s father, Captain Alistair Nimitz to provide Herra with fruits with vitamin C such as strawberries. I am also forwarding this report to the respective sick bays of Captain Nimitz’s so they may prescribe Herra the proper Vitamin C supplement if desired.
LENGTH OF APPOINTMENT: # 0.5 hrs
END OF EVALUATION.
The Centurion is of good health with no pre-existing injuries that would warrant suspension of duties. Will forward these findings through proper channels to Centurion Roris’s superiors in the Romulan Detachment
SUBJECTIVE FINDINGS
The patient was alert and cognitive of her surroundings, and the questions being asked the entire time.
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.
From my scans, I was able to spot a severe fracture to the Centurion’s left arm. It has been fully repaired by whatever medical professional she has worked with in the past. I also found evidence of residual scar tissue near vital organs suggesting a massive load was placed there at one point. This too seems to have healed without any issue as well.
PLAN OF CARE
No current plan of care is required.
LENGTH OF APPOINTMENT: # 0.5 hrs
END OF EVALUATION.
It is this officer’s professional opinion that LT zh’Kytrik is of sound health and is fit to commence their duties at their commander’s discretion
SUBJECTIVE FINDINGS
Patient was awake and cognizant of their surroundings and medical history at all times during the evaluation
OBJECTIVE FINDINGS
Review of Physiological Systems
Section
Status
Comment
HEENT
NAD
Responses normal. (or add your own comment)
Respiration
CTA
Responses normal.
Cardiovascular
AD
High pressure detected.
Abdominal
NAD
NBS, all scans clear.
Extremities
NAD
Responses normal.
Neurological
NAD
Patient was coherent, coordinated and responsive WNL.
This officer found a few items that doesn’t initially concern me given they are past injuries and from the looks of the scans have healed well witing normal parameters. The cause for conern for the LT however stems from higher than normal Blood Pressure compared to Andorian Females of her height and weight.
PLAN OF CARE
It is this Officers professional recommendation that LT zh’Kytrik follows up with Commander Jarnefelt or LT Naderi about a possible treatment plan for the high blood pressure. Additionally, it should be noted that as of this moment, despite the high blood pressure I see no signs of being at risk for further health complications in the short term.
LENGTH OF APPOINTMENT: # 0.5 hrs
END OF EVALUATION.
It is this officer’s professional opinion that the Lt. Commander is of sound health and is able to perform his duties barring nothing arising in their Mental Health Evaluation and the discretion of their commanding officer.
SUBJECTIVE FINDINGS
Patient was alert and cognizant and aware of his medical history during the duration of the evaluation
OBJECTIVE FINDINGS
Review of Physiological Systems
Section
Status
Comment
HEENT
NAD
Responses normal. (or add your own comment)
Respiration
CTA
Responses normal.
Cardiovascular
AD
Pressure above normal limits.
Abdominal
NAD
NBS, all scans clear.
Extremities
NAD
Responses normal.
Neurological
NAD
Patient was coherent, coordinated and responsive WNL.
I have begun to notice a worrying pattern amongst some officers that I think I should address here within objective findings and that is high blood pressure. It is not from using the chemical nicotine, and the Commander does have a history of existing heart conditions. Which I believe puts him at a higher risk for health complications in the future.
PLAN OF CARE
It is this officers opinion that LT. CMDR Garys schedules a follow-up appointment with one of the doctors at his earliest convenience, some things that were discussed were dietary changes among other lifestyle changes. But with prior heart conditions in their history, I find his risk for another episode of them to be quite high.
LENGTH OF APPOINTMENT: # 0.5 hrs
END OF EVALUATION.
The Ensign is cleared for duty pending no abnormalities within Psych Eval. However some concerns are raised.
SUBJECTIVE FINDINGS
Patient was conscious and cognitive of their surroundings and the conversation that took place at all times
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 only abnormality this officer could detect was heighened levels of dairy products within Ensign Van Rijin’s system. Though normally a problem when consumed in normal amounts, the Ensign professed they eat a sandwich with cheese for breakfast, another meal with cheese at lunch and so on.
This officer educated the Ensign on a well balanced and nutritious diet that can be achieved by a) reporting to the Event Horizon prior to their shift, or b) from the comfort of their quarters via a replicator.
PLAN OF CARE
This officer recommends a follow-up with Lieutenant Naderi (@Vix ), Lieutenant Izly (@Motion ), or Commander Jarnefelt (@Eunha ) in a few weeks to investigate if the dairy in the Ensigns system is causing any long-term problems.
LENGTH OF APPOINTMENT: # 0.5hrs
END OF EVALUATION.
Patient is in excellent health and meets all standards of physical fitness. They have passed all testing and evaluation necessary for medical personnel and have no significant medical conditions that bear review.
SUBJECTIVE FINDINGS
Patient made note of previous personal injuries; stating a formerly dislocated shoulder from recklessness on a holodeck, and a broken nose due to a scuffle- both of which supposedly have been taken care of.
OBJECTIVE FINDINGS
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
No plan of care required, officer has displayed injuries are healed and will not obstruct work.
Patient in good overall health and fit for active duty without reservation.
SUBJECTIVE FINDINGS
Patient reports no physical complaints. RFV routine only.
OBJECTIVE FINDINGS
Patient appears healthy for his species with no obvious signs of injury or illness, with the exception of minor spinal strain - likely related to posture, and intestinal bloating - related to lunch. Bioscan confirms no active diseases or injuries. Organ function tests WNL. Labs attached, findings WNL. Previous injuries noted as healed appropriately, consistent with prior medical records.
PLAN OF CARE
Scans recorded in patient’s file for future comparison. No treatment recommended at this time.
Based on the information provided I believe the Lieutenant is in good physical health to carry out his duties within 38th fleet
SUBJECTIVE FINDINGS
The Patient was alert and responsive to my questions during the exam
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.
PLAN OF CARE
Lt. Zexsaber should follow up with Commander Euhna ( @Eunha ) in two weeks time following the discovery of metallic fragments in his ridcage from a stab wound in the past from a Klingon weapon.
LENGTH OF APPOINTMENT: # 0.5 hrs END OF EVALUATION.
Having not the proper authority to further care for the Captain, I recommended a follow-up with CMDR Jarnefelt ( @Eunha ) to discuss the possibility of another operation, to help the Captain in the meantime with pain management I am prescribing 10cc (Ten) of Analgesic
SUBJECTIVE FINDINGS
Captain Skye was alert and answered all of my questions during the exam
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 patient came in expressing interest in updating their medical record. Following both scans from the biobed and tricorder, this officer reviewed the Captain’s Record extensively and found that the Captain has an abnormal amount of scar tissue interacting with the prosthetic limb below her right knee. After describing pain if the Captain sits for longer than a few hours, I began to palpate in the general area before asking the Captain to describe the pain on a scale of one to ten with one being hardly any pain. The answer was a resounding five. Not too uncomfortable, but noticeable. Given the evidence on file, I cannot rule out the possibility that Captain Skye is experiencing the gradual pinching of nerves that is cutting off circulation to her extremities causing pain and discomfort.
PLAN OF CARE
As described in conclusion, Captain Skye is to report to DS13 Medical daily for pain medication while her ship and crew are on leave. While that is occurring, a follow-up with Commander Jarnefelt or any other capable staff should speak to the Captain about an operation to clear scar tissue that has developed. At the Conclusion of MacAlpine’s shore leave, both Medication and report will be forwarded to the proper Authority on board to continue with care and recovery.
