EFTA00135078

# 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: | | |

Reg #:
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>I feel good today,can&#x27;t complain.My anxiety is getting better and I have no side effect from the new anxiety medication 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“I have no idea what was going on.I didn&#x27;t do anything and I have no injury”</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></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></td></tr></tbody></table>

## Blood Pressure:

<table border="1"><tr><td>Date</td><td>Time</td><td>Value</td><td>Location</td><td>Position</td><td>Cuff Size</td><td>Provider</td></tr><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></td></tr></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></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:

Generated 07/31/2019 14:39 by

Bureau of Prisons - NYM



SDNY_00006592 1 of 2
EFTA_00000677


EFTA00135079



SDNY_00006593
EFTA_00000678


EFTA00135080

Inmate Name: TARTAGLIONE  CHOLAS JOHN
Date of Birth: 10/10/1967
Sex: M Race: WHITE
Facility: NYM
Encounter Date: 07/31/2019 14:11
Provider: [Provide Provider]

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 [Name] on 07/31/2019 14:39

Requested to be cosigned by [Name] MD.

Cosign documentation will be displayed on the following page.

EFTA00135081