Medical Record
Lhandon Nilsen/Medical Record
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Lhandon Nilsen
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MEDICAL RECORD
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- Height: 6"4' (193 cm)
- Weight: 235lbs
- Blood Type: AB
- T/E Rating:
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PAST MEDICAL HISTORY
- Chronic Illnesses: None
- Medications: None
- Allergies and Reactions:
- Sexual/Reproductive History:
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PAST HOSPITALIZATIONS/SERIOUS ILLNESS
SD 239804.15: USS Conway Medical Facility - Emergency Treatment:
Severe physical trauma sustained from shuttlecraft incident:
Initial Assessment:
- Upon arrival via emergency transporter to the USS Conway, Cadet Lhandon Joseph Nilsen was unconscious and presented with a severe broken ankle as the primary injury. Further examination revealed possible signs of a concussion. Vital signs were stable, but immediate medical intervention was required.
Treatment::
- Broken Ankle: A complete fracture of the right ankle was diagnosed. Stabilization and immobilization were performed using a hypospray to administer a bone-regenerating agent. A medical brace was applied to support the affected area.
- Concussion: Due to the impact of the crash, signs of a concussion were evident. Nilsen was closely monitored, and cognitive tests were conducted once he regained consciousness.
Follow up:
- His ankle fracture is healing with the applied bone-regenerating agent and the use of a medical brace. The concussion will require close monitoring, and he is advised to rest and avoid strenuous activities until fully recovered.
- As a survivor of a traumatic event, Lhandon may benefit from counseling or support group sessions to address any emotional or psychological challenges resulting from the shuttle crash
SD 239706.25: San Francesco Medical Facility - Walk in:
Broken Nose from Rugby Injury:
Initial Assessment:
- Upon examination, the patient presented with a broken nose sustained during a rugby match. He reported a direct impact to the nose from a collision with another player.
Treatment::
- Broken Nose: The physical examination confirmed a displaced fracture of the nasal bone, resulting in significant swelling and tenderness around the nasal region.
- Epistaxis: The patient experienced a moderate level of epistaxis (nosebleed) as a result of the injury, which was managed promptly.
- Pain Management: Appropriate pain medication was prescribed to manage discomfort and promote a more comfortable recovery. Cadet refused stating that “he was fine and had much worse on the farm”
Follow up:
- Patient comment caused concern, prior medical logs were requested from Gault. Found these logs to be lacking in detail. Suggest further guidance and training for medical professionals on Gault in the logging of patient records.
PAST SURGICAL HISTORY
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PSYCHIATRIC HISTORY
No previous history
SUBSTANCE USE HISTORY
- Alcohol: Very little. Social once every few months
- Recreation Drugs: None
- Other: None
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FAMILY MEDICAL HISTORY
- Parent 1 (Harold Nilsen):
- Parent 2 (Moganie Thompson):
- Siblings:
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SOCIAL HISTORY
- Marital status: None
- Children:
- Occupation/Assignment: Cadet
- Diet:
- Exercise: A regular fitness regium
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PHYSICIANS' NOTES
Cadet Nilsen is in excellent physical condition and enjoys an active lifestyle.
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COUNSELORS' NOTES
Cadet Nilsen does engage with counselling but only to the degree that is required by Starfleet. The cadet seems to have a distrust of counselors and has not yet sought out further support.
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