EFTA00061607.pdf

Li From: To: Cc: Subject: medical assessment Date: Friday, August 9, 2019 3:11:05 PM Attachments: nab= OnicalEnrountrFinaveramOoCurnent.lasratf Inmate Name LT, U.S. Public Health Service Physician Assistant MCC New York 150 Park Row, New York NY 10007 EFTA00061607  Bureau of Prisons Health Services Clinical Encounter Inmate Name: Reg #: Date of Birth: Sex: M Race: Facility: NYM Encounter Date: 19 15:01 Provider: Unit Z05 Injury Assessment - Non-work related encounter performed at Health Services. SUBJECTIVE: INJURY 1 Provider: Date of Injury: 08/09/2019 14:30 Date Reported for Treatment: 08/09/2019 15:01 Work Related: No Work Assignment: UNASSG Pain Location: Pain Scale: 0 Pain Qualities: Where Dld Injury Happen (Be specific as to location): No injuries, Pt. Is being placed on Dry cell. Medical assessment requested by the LT. Cause of Injury (Inmate's Statement of how injury occurred): ▪ I have no injuries" Symptoms (as reported by inmate): ' I have no injuries" OBJECTIVE: Pulse: Pik Time Rate Per Minute 1,OCatkin Rhythm Provider 08/09/2019 15:00 64 Via Machine Blood Pressure: Pik Time Value Location Positiont Cuff Size Provider 08/09/2019 15:00 NYM 130/74 Left Arm Sitting Adult-regular SaO2: Date Time Valuel%1 Ail: Provider 08/09/2019 15:00 NYM 99 Room Air Exam Comments Injury- Neg objective findings. FACE: no erythema, no edema, no opening into skin, no abrasions, no laceration, no ecchymosis, non tender to palpation, no signs of acute trauma, old healing ecchymosis on the right periorbital area noted from zygomatic fx. TORSO (front and back) no erythema, no edema, no laceration, no ecchymosis, nl, rom, non tender to palpation UPPER EXT: no erythema, no edema, no opening into skin, no abrasions, no laceration, no ecchymosis, no signs of acute trauma, no bony deformity noted, non tender to palpation LOWER EXT: no erythema, no edema, no opening into skin, no abrasions, no laceration, no ecchymosis, no signs of acute trauma, no bony deformity noted, non tender to palpation Mouth/inner Mucosa, no abrasions, no lacerations, no edema, no bleeding gums or loose teeth noted Generated 08/09/2019 15:09 by Bureau of Prisons - NYM Page 1 of 2 EFTA00061608 Inmate Name: Reg #: == Date of Birth: Sex: Facility: NYM Encounter Date: 08/09/201915:01 Provider: Unit: Z05 ASSESSMENT: Constipation, unspecified, K5900 - Current Unspecified place or not applicable of injury/occurrence, Y929 - Current PLAN: New Medication Orders: Medication Order Date Prescriber Order Docusate Sodium Capsule 08/09/2019 15.01 100mg Orally - daily x 10 day(s) — 1 refill Indication: Constipation, unspecified Disposition: Follow-up at Sick Call as Needed Return Immediately if Condition Worsens Other. Neg subjective and objective findings. pt. states he is constipated and he goes <3sAveek. will rx laxative. Patient Education Topics: Dote Initiated Format Handout/Toolc Provider Outcome 08/09/2019 Counseling Access to Care Verbalizes Understanding Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Completed by on 08/09/2019 15:09 Requested to be cosigned by Cosign documentation will be displayed on the following page. Generated 08/09/2019 15 09 by Bureau of Prisons • NYM Page 2 of 2 EFTA00061609