EFTA00132475

Bureau of Prisons Health Services Clinical Encounter

| Inmate Name: | TARTAGLIONE, NICHOLAS JOHN |
| :--- | :--- |
| Date of Birth: | 10/10/1967 |
| Encounter Date: | 07/31/2019 14:11 |

| | Sex: | M | Race: | WHITE |
| :--- | :--- | :--- | :--- | :--- |
| | Provider: | | | PA-C |

| | | | | Reg #: | 78514-054 |
| :--- | :--- | :--- | :--- | :--- | :--- |
| | | | | Facility: | NYM |
| | | | | Unit: | Z06 |

Mid Level Provider - Evaluation encounter performed at Special Housing Unit.

## SUBJECTIVE:

## COMPLAINT 1

<table border="1"><tr><td colspan="2">Chief Complaint: No Complaint(s)</td></tr><tr><td>Subjective:</td><td>&quot;I feel good today,can&#x27;t complain.My anxiety is getting better and I have no side effect from the new anxiety medication&quot;

IM being seen in the SHU as per the request of lieutenants.

States he&#x27;s been doing well and has no acute complaints.

For what happened to his previous cell mate about a week ago,states &quot;I have no idea what was going on.I didn&#x27;t do anything and I have no injury&quot;</td></tr><tr><td>Pain:</td><td>No</td></tr></table>

## OBJECTIVE:

## Pulse:

<table><thead><tr><th>Date</th><th>Time</th><th>Rate Per Minute</th><th>Location</th><th>Rhythm</th><th>Provider</th></tr></thead><tbody><tr><td>07/31/2019</td><td>14:19</td><td>71</td><td>Via Machine</td><td></td><td>PA-C</td></tr></tbody></table>

## Respirations:

<table><thead><tr><th>Date</th><th>Time</th><th>Rate Per Minute</th><th>Provider</th></tr></thead><tbody><tr><td>07/31/2019</td><td>14:19 NYM</td><td>15</td><td>PA-C</td></tr></tbody></table>

## Blood Pressure:

<table><thead><tr><th>Date</th><th>Time</th><th>Value</th><th>Location</th><th>Position</th><th>Cuff Size</th><th>Provider</th></tr></thead><tbody><tr><td>07/31/2019</td><td>14:19 NYM</td><td>118/70</td><td>Left Arm</td><td>Sitting</td><td>Adult-regular</td><td>PA-C</td></tr></tbody></table>



SaO2:


<table><thead><tr><th>Date</th><th>Time</th><th>Value(%)</th><th>Air</th><th>Provider</th></tr></thead><tbody><tr><td>07/31/2019</td><td>14:19 NYM</td><td>98</td><td>Room Air</td><td>PA-C</td></tr></tbody></table>

## Exam Comments

<table border="1"><tr><td>General: AAOx3. NAD</td></tr><tr><td>HEENT: PERRLA. EOMI. Nares patent.</td></tr><tr><td>Neck: Supple</td></tr><tr><td>Heart: S1, S2. RRR</td></tr><tr><td>Lungs: CTAB</td></tr><tr><td>EXT: No edema.</td></tr><tr><td>Neuro: Grossly normal CN II-XII</td></tr></table>

## ASSESSMENT:

Encounter for general adult medical exam without abnormal findings, Z0000 - Current

## PLAN:

## Disposition:

Follow-up at Sick Call as Needed

## Other:

Bureau of Prisons - NYM

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EFTA00132476

EFTA00132477

Inmate Name: TARTAGLIONE CHOLAS JOHN
Date of Birth: 10/10/1967
Encounter Date: 07/31/2019 14:11
Provider: PA-C

Reg #: 78514-054
Facility: NYM
Unit: Z06

IM states he feels as himself and denies being in acute distress.

Patient Education Topics:
Date Initiated Format Handout/Topic Provider Outcome
07/31/2019 Counseling Access to Care Verbalizes Understanding

Copay Required: No Cosign Required: Yes

Telephone/Verbal Order: No
Completed by PA-C on 07/31/2019 14:39
Requested to be cosigned by MD.
Cosign documentation will be displayed on the following page.