Text extracted via OCR from the original document. May contain errors from the scanning process.
Li
From:
To:
Cc:
Subject:
Date:
Attachments:
medical assessment
Friday, August 9, 2019 3:11:05 PM
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:
Date of Birth:
Encounter Date:
19 15:01
Reg #:
Sex:
M
Race:
Facility: NYM
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:
Date of Birth:
Encounter Date: 08/09/201915:01
Sex:
Provider:
Reg #: ==
Facility: NYM
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
08/09/2019
Counseling
Access to Care
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
Provider
Outcome
Verbalizes
Understanding
Bureau of Prisons • NYM
Page 2 of 2
EFTA00061609