The Patient came for their standard baseline medical assessment and meets all standards required. Some internal scarring was found however this was normal given patients medical history and he is healing/healed and is fit for full active duty.
SUBJECTIVE FINDINGS
Patient wears a visor as a result of an accident and scans revealed scarring behind his eyes, as well as on his heart and lungs as well. All have been healing naturally as a result on an accident the patient had when they were much younger. Patient takes occasional immune suppressants to assist with visor as standard procedure.
OBJECTIVE FINDINGS
All test results were within normal parameters.
Review of Physiological Systems
Section
Status
Comment
HEENT
NAD
Responses normal.
Respiration
CTA
Responses normal.
Cardiovascular
NAD
Pulse within normal limits, Blood pressure on the low side but still within safe limits.
Abdominal
NAD
NBS, all scans clear.
Extremities
NAD
Responses normal.
Neurological
NAD
Patient was coherent, coordinated and responsive WNL.
PLAN OF CARE
Patient will be required to attend semi-regular appointments for check-ups on his visor to ensure all is functioning correctly.
Patient is healthy in accordance with species and age. Fit for full duty.
SUBJECTIVE FINDINGS
Patient reports a lack of sleep in the past couple days due to job change.
OBJECTIVE FINDINGS
This officer’s findings support the complaint of fatigue and agree the cause is due to stress from changing on environments and starting a new job with increased responsibilities. Fatigue is negligible and will go away as patient adjusts to new environment and falls into a regular rest cycle.
PLAN OF CARE
N/A
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: .835 hrs END OF EVALUATION.
Patient has no significant illness or injury and is rated fit for duty.
SUBJECTIVE FINDINGS
Patient has mild scarring around right eye from trauma sustained prior to Starfleet service. Eye and supporting structures were replaced during treatment. Transplant healthy and functional.
OBJECTIVE FINDINGS
Vital statistics are within normal limits.
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.
Well quite high in number, the very minor injuries treated are frankly expected of a serious close combat instructor and practitioner. Even untreated they in no way would have affected his ability to perform his duties. However, treatment was given for the sake of overall health. There was no need to leave the injuries as they were when treatment could bring the patient back to full health
SUBJECTIVE FINDINGS
No complaints of pain or difficulties with breathing chest pain bleeding nor infection. Patient appears to consider this a normal consequence of training and practicing in his chosen martial art.
OBJECTIVE FINDINGS
Multiple minor abrasions about the hands especially the knuckles. Contusions on all four limbs. again not serious.
open wounds treated with antibiotic/disinfectant spray and Sprayskin. Contusions treated with a vascular recontructor and blood decoagulator.
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.
Patient has no significant illness or injury and is rated fit for duty.
SUBJECTIVE FINDINGS
Patient reported a malfunction in a Borg legacy ocular implant. Recalibration of the implant corrected the issue.
OBJECTIVE FINDINGS
CMDR Flynn is in good health, but experiences discomfort due to excessive scar tissue at various implant removal sites. I advised her that protoplasic intervention may provide some relief. She will contact us when ready for treatment.
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.
Patient is extremely healthy in accordance with species and age. Fit for full duty.
SUBJECTIVE FINDINGS
Patient reports an eye discomfort with light environments of federation ships and stations and has been using eye drops on occasion for which. Patient has also stated that the patient’s CMO will be providing contact lenses to better alleviant the discomfort.
OBJECTIVE FINDINGS
Nothing abnormal was picked up during scans, patient is in perfect health.
PLAN OF CARE
N/A
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: 1.305 hrs END OF EVALUATION.
LT. Seonu is fit for duty, though duty will come with certain complications
SUBJECTIVE FINDINGS
LT. Seonu appeared conscious and answered all my questions in a likewise manner. The LT. did exhibit some concerning behavior that counseling may want to address, such as tensing up with medical personnel.
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
This is a unique case to which I am personally going to devote special attention too. The LT clearly has had rough encounters in the past specifically with Rhiannsu and Medical teams. To that end, I would like to conduct regular checkups with the Lieutenant. I first need to contact our allies within the Republic about common Tal’Shiar torture devices before any surgical procedure can be scheduled to repair LT Seonu’s synaptic pathways to restore her ability to physically speak.
Medical Routine Exam - Patient scheduled appointment coinciding with new assignment to starbase. Performed sequentially following unscheduled visit.
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.
▼ Albumin ▲ bCG ▲ Cholesterol ▲ Creatinine
▼ Potassium ▲ Progesterone ▼ Protein (total) ▼ Psilosynine
▼ Sodium ▼ 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.
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.
Patient is within health standards for species and age. Fit for full duty.
SUBJECTIVE FINDINGS
Patient stated they are fit, with minor stress induced headaches. Patient has stated they already informed their responsible medical officers and has a treatment plan.
OBJECTIVE FINDINGS
Scans confirm patient is healthy and fit for based on species and age.
PLAN OF CARE
N/A
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: 1.666hrs END OF EVALUATION.
PATIENT’S NAME:
Commander Marinov, U @FlaccidPancake APPOINTMENT STARDATE:
99591.6
PURPOSE AND CONTEXT OF EVALUATION
Baseline Medical Assessment
CONCLUSION
Patient is well within health standards for species and age. Fit for full duty.
SUBJECTIVE FINDINGS
Patient states they are in good health.
OBJECTIVE FINDINGS
Scans for the patient all came back normal he is fit and healthy. There is some abnormalities with the respiration system however this is a result of his growing-up on a mining world.
PLAN OF CARE
Keep eye on respiration system - if begins to cause any problems bring in for treatment.
Review of Physiological Systems
Section
Status
Comment
HEENT
NAD
Responses normal.
Respiration
CTA
Responses normal. Some abnormalities.
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.
Patient is within health standards for species and age. Fit for full duty.
SUBJECTIVE FINDINGS
Patient states they are in relative good health. Arrived with minor muscle fatigue associated with exercise, which has been treated with a relaxant and recommendation for a good naturally healing food.
OBJECTIVE FINDINGS
Scans detected an older deep bruise or sprain that is the result of a fall down a ladderwell and improperly treated by patient. Injury has been corrected.
PLAN OF CARE
N/A
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: 1.023hrs END OF EVALUATION.
Lt. Lalaa presented herself to me at medical after the Midway secured from combat operations for treatment of burns on her leg and hand from an exploding panel while the Midway was facing a Borg Sphere. The Lt. seems to have a strong reaction to cellular regeneration and the Lt. wanted to scratch at the tissue. As such a more powerful nerve inhibitor field was applied to the sites to dissuade her from that course of action. After Regeneration was complete the LT was released to full duty with recommendation to wear pants in the future while on duty.
SUBJECTIVE FINDINGS
Lt. Lalaa cited multiple complaints against itchy sensations during the course of treatment.
OBJECTIVE FINDINGS
Lt. Lalaa left fully ambulatory and with full control of all of her facilities.
PLAN OF CARE
Lt. Lalaa should return to medical in one week to ensure there are no complications with the regenerated tissue.
LENGTH OF APPOINTMENT: ~ 1 hour END OF EVALUATION.
Subject seems to be in good health and eager to join the fleet. Released with a Fit for Full Duty evaluation.
SUBJECTIVE FINDINGS
Subject claims to be as fit as a horse.
OBJECTIVE FINDINGS
Subject’s scans return clear of any major issues. There are a couple of scars that a cellular regeneration treatment could remove, which makes them seem intentionally kept.
LENGTH OF APPOINTMENT: ~ 1 Hour END OF EVALUATION.