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¶
| Chief Complaint: No Complaint(s) | |
| Subjective: | I feel good today,can'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'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't do anything and I have no injury” |
| Pain: | No |
OBJECTIVE:¶
Pulse:¶
| Date | Time | Rate Per Minute | Location | Rhythm | Provider |
|---|---|---|---|---|---|
| 07/31/2019 | 14:19 | 71 | Via Machine |
Respirations:¶
| Date | Time | Rate Per Minute | Provider |
|---|---|---|---|
| 07/31/2019 | 14:19 NYM | 15 |
Blood Pressure:¶
| Date | Time | Value | Location | Position | Cuff Size | Provider |
| 07/31/2019 | 14:19 NYM | 118/70 | Left Arm | Sitting | Adult-regular |
SaO2:¶
| Date | Time | Value(%) | Air | Provider |
|---|---|---|---|---|
| 07/31/2019 | 14:19 NYM | 98 | Room Air |
Exam Comments¶
| General: AAOx3. NAD |
| HEENT: PERRLA. EOMI. Nares patent. |
| Neck: Supple |
| Heart: S1, S2. RRR |
| Lungs: CTAB |
| EXT: No edema. |
| Neuro: Grossly normal CN II-XII |
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¶