Taryn Slater/Medical Record: Difference between revisions

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{{Medical Record LCARS
{{Medical Record LCARS
|SERIAL NUMBER= EZ - 123 - 456
|SERIAL NUMBER= UV - 927 - 246
|BIRTHYEAR= 2363
|BIRTHYEAR= 2372
|BIRTHMONTH= 01
|BIRTHMONTH= 08
|BIRTHDATE= 01
|BIRTHDATE= 23
|SEX= Female
|SEX= Female
|SPECIES= [[Human]]
|SPECIES= [[Human]]
|HEIGHT= 161 cm (5'3")
|HEIGHT= 173 cm (5'8")
|WEIGHT= 56 kilos (123 lbs)
|WEIGHT= 68 kilos (149 lbs)
|BLOOD TYPE= B+
|BLOOD TYPE= B+
|T/E RATING= T0
|T/E RATING= T0
|CHRONIC ILLNESSES= None
|CHRONIC ILLNESSES= None
|MEDICATIONS= None
|MEDICATIONS= None regularly (see Doctor's Notes)
|ALLERGIES & REACTIONS= Strawberries (hives)
|ALLERGIES & REACTIONS= Penicillin
|SEXUAL/REPRODUCTIVE HISTORY= Longterm male partner
|SEXUAL/REPRODUCTIVE HISTORY= Refused to answer
|PAST HOSPITALIZATIONS/SERIOUS ILLNESS=
|PAST HOSPITALIZATIONS/SERIOUS ILLNESS=
*'''2388:''' Tarkalean flu
*None
|PAST SURGICAL HISTORY=
|PAST SURGICAL HISTORY=
*'''SD 238911.12:''' Knee surgery
*None
**'''Surgeon:''' {{n|Niccolò|del Vedova}}, MD
**'''OR Site:''' {{USS|Mercury}}
**'''Op Note:''' Link to sim
|PSYCHIATRIC HISTORY= None
|PSYCHIATRIC HISTORY= None
|ALCOHOL USE= 2 glasses of wine per week
|ALCOHOL USE= Twice a week
|RECREATIONAL DRUG USE= None
|RECREATIONAL DRUG USE= None
|OTHER SUBSTANCE USE= None
|OTHER SUBSTANCE USE= None
|MOTHER MEDICAL HISTORY= None
|MOTHER MEDICAL HISTORY= Hypertension
|FATHER MEDICAL HISTORY= Cardiovascular disease
|FATHER MEDICAL HISTORY= None
|SIBLING MEDICAL HISTORY= None
|SIBLING MEDICAL HISTORY= None
|MARITAL STATUS & SPOUSE= Married to Elliot Smith
|MARITAL STATUS & SPOUSE= Single
|CHILDREN= 1 son
|CHILDREN= None
|OCCUPATION= Helmsman
|OCCUPATION= Security/Tactical Officer
|DIET= Vegetarian
|DIET= Omnivore. 2300 calories or more per day.
|EXERCISE= Running, 3 times a week
|EXERCISE= Moderate to Intense activity 6 days per week.
|PHYSICIANS NOTE=
|PHYSICIANS NOTE=
*'''SD 239004.23 - Medical Officer:''' {{n|Niccolò|del Vedova}}, MD, {{USS|Mercury}}
*'''SD 239003.12 - Medical Officer:''' Lt. Juliana Abbing, MD, Starfleet Academy
*'''Medical Assessment:''' Ensign Smith is a 27-year-old human female who presents with abdominal pain and generalized weakness. She states the symptoms began last Thursday after eating a bowl of Commander McLaughin's "Sweet Chili Surprise" at the ship's annual cook off contest. I've started her on an intense bowel cleansing therapy which should be followed to completion through next week.
*'''Medical Assessment:''' Candidate Slater is an 18 year old human female, in perfect health. Reports moderately active lifestyle and analysis of medical questionnaire suggests no propensity to disqualifying conditions. All exams normal. Patient has renal agenesis of the left kidney, though it has no effect on her current state of health. Fit for entry into Starfleet Academy.
<hr>
<hr>
*'''SD 239004.27 - Medical Officer:''' {{n|Niccolò|del Vedova}}, MD, {{USS|Mercury}}
*'''SD 239007.15 - Medical Officer:''' Commander Isa Atteberry, MD, Starfleet Academy
*'''Addendum:''' Ensign Smith returned to sickbay today stating she felt much better, insisting that her cleansing therapy was no longer necessary. I told her nonsense and sent her on her way.
*'''Chief Complaint:''' Moderate abdominal pain due to cramps.
|COUNSELORS NOTE=
*'''Exams:''' Clinical exam and imaging scans ruled out appendicitis. Diagnosis made on basis of clinical history.
*'''SD 239004.28 - Counselor:''' Lt. Rachel Simmons, {{USS|Mercury}}
*'''Diagnosis:''' Dysmenorrhea.
*'''Counseling Assessment:''' Ensign Smith came to my office today in tears. It seems her recent medical illness due to her unfortunate encounter with McLaughlin's chili has left her feeling vulnerable and alone. I have advised her to continue daily therapy sessions with me until further notice.
*'''Prescribed Treatment:''' Ibuprofen 200 mg, 1 tablet in case of pain.
<hr>
*'''SD 239007.15 - Medical Officer:''' Commander Isa Atteberry, MD, Starfleet Academy
*'''Chief Complaint:''' Moderate abdominal pain due to cramps.
*'''Exams:''' Clinical exam and imaging scans ruled out appendicitis. Diagnosis made on basis of clinical history.
*'''Diagnosis:''' Dysmenorrhea.
*'''Prescribed Treatment:''' Ibuprofen 200 mg, 1 tablet in case of pain.
<hr>
*'''SD 239008.29 - Medical Officer:''' Commander Isa Atteberry, MD, Starfleet Academy
*'''Chief Complaint:''' Nausea and headache.
*'''Exams:''' Clinical exam and regular scans normal. Patient appears to be completely healthy and possibly seeking to avoid class. Reported.
*'''Diagnosis:''' None.
*'''Prescribed Treatment:'''None.
<hr>
*'''SD 239101.17 - Medical Officer:''' Lieutenant JG Eiran MacCarthy, MD, Starfleet Academy
*'''Chief Complaint:''' Moderate abdominal pain.
*'''Exams:''' Clinical exam and imaging scans normal. Clinical history suggests Dysmenorrhea.
*'''Diagnosis:''' Dysmenorrhea.
*'''Prescribed Treatment:'''Ibuprofen 200 mg, 1 tablet in case of pain.
<hr>
*'''SD 239102.22 - Medical Officer:''' Lt. Illarion Tangeman, MD, Starfleet Academy
*'''Medical Assessment:''' Cadet Slater in perfect health. All exams normal. Renal agenesis of the left kidney with no significant effects. Fit for service.
<hr>
*'''SD 239105.13 - Medical Officer:''' Commander Isa Atteberry, MD, Starfleet Academy
*'''Chief Complaint:''' Moderate abdominal pain.
*'''Exams:''' Appendicities ruled out with clinical exam. Dx made based on past clinical history.
*'''Diagnosis:''' Dysmenorrhea.
*'''Prescribed Treatment:'''Ibuprofen 200 mg, 1 tablet in case of pain.
<hr>
*'''SD 239107.29 - Medical Officer:''' Lieutenant Commander Maja Kaspar, MD, Starfleet Academy
*'''Chief Complaint:''' Frequent Dysmenorrhea
*'''Exams:''' Clinical history and exam performed.
*'''Diagnosis:''' Dysmenorrhea.
*'''Prescribed Treatment:''' Ibuprofen 600 mg, 1 tablet in case of pain.
<hr>
*'''SD 239111.14 - Medical Officer:''' Lt. Illarion Tangeman, MD, Starfleet Academy
*'''Chief Complaint:''' Dysmenorrhea
*'''Exams:''' Clinical exam.
*'''Diagnosis:''' Dysmenorrhea.
*'''Prescribed Treatment:''' Ibuprofen 600 mg, 1 tablet in case of pain.
<hr>
*'''SD 239203.01 - Medical Officer:''' Commander Isa Atteberry, MD, Starfleet Academy
*'''Medical Assessment:''' Cadet in perfect health. All exams normal. Renal agenesis of the left kidney with no significant effects. Fit for service.
<hr>
*'''SD 239206.11 - Medical Officer:''' Lt. Illarion Tangeman, MD, Starfleet Academy
*'''Chief Complaint:''' Dysmenorrhea.
*'''Exams:''' Clinical exam.
*'''Diagnosis:''' Dysmenorrhea.
*'''Prescribed Treatment:''' Ibuprofen 600 mg, 1 tablet in case of pain.
<hr>
*'''SD 239302.27 - Medical Officer:''' Commander Isa Atteberry, MD, Starfleet Academy
*'''Medical Assessment:''' Cadet in perfect health. All exams normal. Renal agenesis of the left kidney with no significant effects. Fit for service.
<hr>
*'''SD 239304.16 - Medical Officer:''' Lt. Juliana Abbing, MD, Starfleet Academy
*'''Chief Complaint:''' Painful menstrual cramps
*'''Exams:''' Clinical exam.
*'''Diagnosis:''' Dysmenorrhea.
*'''Prescribed Treatment:''' Ibuprofen 600 mg, 1 tablet in case of pain. Rest.
<hr>
*'''SD 239401.18 - Medical Officer:''' Commander Isa Atteberry, MD, Starfleet Academy
*'''Medical Assessment:''' Cadet in perfect health. All exams normal. Renal agenesis of the left kidney with no significant effects. Fit for service.
}}
}}


[[Category:Medical Records]]
[[Category:Medical Records]]

Latest revision as of 13:08, 18 November 2017

Starfleet Medical.png

Taryn Slater

MEDICAL RECORD
  • Height: 173 cm (5'8")
  • Weight: 68 kilos (149 lbs)
  • Blood Type: B+
  • T/E Rating: T0

PAST MEDICAL HISTORY

  • Chronic Illnesses: None
  • Medications: None regularly (see Doctor's Notes)
  • Allergies and Reactions: Penicillin
  • Sexual/Reproductive History: Refused to answer

PAST HOSPITALIZATIONS/SERIOUS ILLNESS

  • None

PAST SURGICAL HISTORY

  • None

PSYCHIATRIC HISTORY

None

SUBSTANCE USE HISTORY

  • Alcohol: Twice a week
  • Recreation Drugs: None
  • Other: None

FAMILY MEDICAL HISTORY

  • Parent 1 (Mother): Hypertension
  • Parent 2 (Father): None
  • Siblings: None

SOCIAL HISTORY

  • Marital status: Single
  • Children: None
  • Occupation/Assignment: Security/Tactical Officer
  • Diet: Omnivore. 2300 calories or more per day.
  • Exercise: Moderate to Intense activity 6 days per week.

PHYSICIANS' NOTES

  • SD 239003.12 - Medical Officer: Lt. Juliana Abbing, MD, Starfleet Academy
  • Medical Assessment: Candidate Slater is an 18 year old human female, in perfect health. Reports moderately active lifestyle and analysis of medical questionnaire suggests no propensity to disqualifying conditions. All exams normal. Patient has renal agenesis of the left kidney, though it has no effect on her current state of health. Fit for entry into Starfleet Academy.
  • SD 239007.15 - Medical Officer: Commander Isa Atteberry, MD, Starfleet Academy
  • Chief Complaint: Moderate abdominal pain due to cramps.
  • Exams: Clinical exam and imaging scans ruled out appendicitis. Diagnosis made on basis of clinical history.
  • Diagnosis: Dysmenorrhea.
  • Prescribed Treatment: Ibuprofen 200 mg, 1 tablet in case of pain.
  • SD 239007.15 - Medical Officer: Commander Isa Atteberry, MD, Starfleet Academy
  • Chief Complaint: Moderate abdominal pain due to cramps.
  • Exams: Clinical exam and imaging scans ruled out appendicitis. Diagnosis made on basis of clinical history.
  • Diagnosis: Dysmenorrhea.
  • Prescribed Treatment: Ibuprofen 200 mg, 1 tablet in case of pain.
  • SD 239008.29 - Medical Officer: Commander Isa Atteberry, MD, Starfleet Academy
  • Chief Complaint: Nausea and headache.
  • Exams: Clinical exam and regular scans normal. Patient appears to be completely healthy and possibly seeking to avoid class. Reported.
  • Diagnosis: None.
  • Prescribed Treatment:None.
  • SD 239101.17 - Medical Officer: Lieutenant JG Eiran MacCarthy, MD, Starfleet Academy
  • Chief Complaint: Moderate abdominal pain.
  • Exams: Clinical exam and imaging scans normal. Clinical history suggests Dysmenorrhea.
  • Diagnosis: Dysmenorrhea.
  • Prescribed Treatment:Ibuprofen 200 mg, 1 tablet in case of pain.
  • SD 239102.22 - Medical Officer: Lt. Illarion Tangeman, MD, Starfleet Academy
  • Medical Assessment: Cadet Slater in perfect health. All exams normal. Renal agenesis of the left kidney with no significant effects. Fit for service.
  • SD 239105.13 - Medical Officer: Commander Isa Atteberry, MD, Starfleet Academy
  • Chief Complaint: Moderate abdominal pain.
  • Exams: Appendicities ruled out with clinical exam. Dx made based on past clinical history.
  • Diagnosis: Dysmenorrhea.
  • Prescribed Treatment:Ibuprofen 200 mg, 1 tablet in case of pain.
  • SD 239107.29 - Medical Officer: Lieutenant Commander Maja Kaspar, MD, Starfleet Academy
  • Chief Complaint: Frequent Dysmenorrhea
  • Exams: Clinical history and exam performed.
  • Diagnosis: Dysmenorrhea.
  • Prescribed Treatment: Ibuprofen 600 mg, 1 tablet in case of pain.
  • SD 239111.14 - Medical Officer: Lt. Illarion Tangeman, MD, Starfleet Academy
  • Chief Complaint: Dysmenorrhea
  • Exams: Clinical exam.
  • Diagnosis: Dysmenorrhea.
  • Prescribed Treatment: Ibuprofen 600 mg, 1 tablet in case of pain.
  • SD 239203.01 - Medical Officer: Commander Isa Atteberry, MD, Starfleet Academy
  • Medical Assessment: Cadet in perfect health. All exams normal. Renal agenesis of the left kidney with no significant effects. Fit for service.
  • SD 239206.11 - Medical Officer: Lt. Illarion Tangeman, MD, Starfleet Academy
  • Chief Complaint: Dysmenorrhea.
  • Exams: Clinical exam.
  • Diagnosis: Dysmenorrhea.
  • Prescribed Treatment: Ibuprofen 600 mg, 1 tablet in case of pain.
  • SD 239302.27 - Medical Officer: Commander Isa Atteberry, MD, Starfleet Academy
  • Medical Assessment: Cadet in perfect health. All exams normal. Renal agenesis of the left kidney with no significant effects. Fit for service.
  • SD 239304.16 - Medical Officer: Lt. Juliana Abbing, MD, Starfleet Academy
  • Chief Complaint: Painful menstrual cramps
  • Exams: Clinical exam.
  • Diagnosis: Dysmenorrhea.
  • Prescribed Treatment: Ibuprofen 600 mg, 1 tablet in case of pain. Rest.
  • SD 239401.18 - Medical Officer: Commander Isa Atteberry, MD, Starfleet Academy
  • Medical Assessment: Cadet in perfect health. All exams normal. Renal agenesis of the left kidney with no significant effects. Fit for service.

COUNSELORS' NOTES

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