Vesicular Breath Sounds Bilaterally
PERSONPulmonary/Respiratory, Orthopedic/Rheumatology
ORGANIZATION6
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Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: MOM Unit: HO1 Exam: Acutely III Pulmonary Auscultation Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally No: Crackles, Rhonchi, Wheezing Exam Comments Inmate for injury report as requested by Operational Lt. He is ambulatory, oriented x 3. In not app
IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-MEDICAL ISSUES. STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Seen for clinic(s): Pulmonary/Respiratory, Orthopedic/Rheumatology, Endocrine/Lipid OBJECTIVE: Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed
Sex: M Race: WHITE Facility: NYM Provider: Joaquin, Y. MLP Unit: H01 Exam: Acutely III Pulmonary Auscultation Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally No: Crackles, Rhonchi, Wheezing Exam Comments Inmate for injury report as requested by Operational Lt. He is ambulatory, oriented x 3. In not app
IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-MEDICAL ISSUES. STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Seen for clinic(s): Pulmonary/Respiratory, Orthopedic/Rheumatology, Endocrine/Lipid OBJECTIVE: Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed
ITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: Unit: H01 Exam: Acutely III Pulmonary Auscultation Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally No: Crackles, Rhonchi, Wheezing Exam Comments Inmate for injury report as requested by Operational Lt. He is ambulatory, oriented x 3. In not app
IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-MEDICAL ISSUES. STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Seen for clinic(s): Pulmonary/Respiratory, Orthopedic/Rheumatology, Endocrine/Lipid OBJECTIVE: Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed
e: WHITE Encounter Date: 07/23/2019 06:20 Exam: Acutely Ill Pulmonary Auscultation Provider: b)(5>; (b)(l)(Cl MLP Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally No: Crackles, Rhonchi, Wheezing Exam Comments (b)(7:(A) ASSESSMENT: Injury, unspecified, T1490 - Current - RIO self inflicted injuries. PLAN:
IT WILL BE GIVEN TO HIM TONIGHT .. HE REPORT OTHER NON-MEDICAL ISSUES. STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Seen for clinic(s): Pulmonary/Respiratory, Orthopedic/Rheumatology, Endocrine/Lipid OBJECTIVE: Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed
07/23/2019 06:20 Exam: Acutely Ill Pulmonary Auscultation Sex: M Race: WHITE Provider: l(b)t5,; (o)(7)tC) IMLP Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally No: Crackles, Rhonchi, Wheezing Exam Comments (b)(7)(A) ASSESSMENT: Injury, unspecified, T1490 - Current - RIO self inflicted injuries. PLAN:
eason Not Done: Comments: Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology Added to clinic(s): Endocrine/lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology OBJECTIVE: Exam: General Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pa
cility: NYM Encounter Date: 07/23/2019 06:20 Provider: . MLP Unit: H01 Exam: Acutely III Pulmonary Auscultation Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally No: Crackles, Rhonchi, Wheezing Exam Comments Inmate for injury report as requested by Operational Lt. He is ambulatory, oriented x 3. In not app
IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-MEDICAL ISSUES. STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Seen for clinic(s): Pulmonary/Respiratory, Orthopedic/Rheumatology, Endocrine/Lipid OBJECTIVE: Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed
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