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George Zimmerman Medical Report

George Zimmerman Medical Report

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Published by tpmdocs
Report on George Zimmerman's injuries the day after he killed teenager Trayvon Martin.
Report on George Zimmerman's injuries the day after he killed teenager Trayvon Martin.

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Published by: tpmdocs on Jul 03, 2012
Copyright:Attribution Non-commercial

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11/23/2014

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03/09/2012 15:57 To: attn: Investigator
Si.
Attn:
From:
Altamonte
Family
Practice
Fax.8304300,
Phone:4073326366 Page 1
of
4
Fax
Date: 03/09/20
12
Recipient:
Fax Number: 4076885071Sender:
Zelaya,
AshleyNumber of pages
mck1ding
Cover: 4
Comments:
Altamonte FamilyPractice
249 Maittand
Ave Ste
1000
Altamonte
Springs,
FL
32701
Phone:407-332-6366
fax:
407-830-4300
Prtv3cy
~:
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. 03/09/2012
15:57 To:
attn:
InvestigatorS.
Attn:
From:
Altamonte
Family
Practice
Fa-8304300,
Phone:4073326366
Page
2
of
4
Altamonte
Family
Practice
249
Maitland
Ave Ste
1
ooo
Altamonte Springs,
FL
32701
Phone:
407-332-6366
Fa·x:
407 830·4300
Patient:
GEORGE
M
ZIMMERMAN,
28
year
old
Male,
Race:
While,
SSN: XXX-XX-9331,
DOB:
10/05/1983
Encounter
Date:
02127/2012
11:02 am
Encounter Closed
Date:03/09/2012
03:37pm
lication
Plan:
Decision
Making
Process:
..
Follow
up:
a~
previously scheduled
for
routine follow
up
Call
if
any problems before the
next
visit. 512012
with
LF
..
MEDS: Continue present
tx.
Risks, benefits
&
side effects
were
discussed.
Add
Lodine
BID PAN
for
Sl
Joint
pain. Use
cautiously given
dx
of
IBS.
; •
Pl
Education {physician):
Discussed
Ox and
Tx
plan, symptomatic
tx
and
reassurance.
1.
Scalp
Lacerations:
No
sutures needed given
well-approximated skin
margins. Continue
to
clean
with
soap
and waterdally.
We
discussed
the
red flag
symptoms that
would warrant Imaging given
the
type
of
assault
he
sustained.
Given
thetype
of
trauma,
we discussedthat
it
Is
imperative
he
be seen
with
his
Psychologist
for
evaluation.
2.
Broken
Nose~
We
discussed that
it
is likely
broken,
but
does not
appear to have septal
devialion. The
swelling and
black
e.yes
are typical
of this
injury. I
recommended
that
he
be
evaluated
by
ENT
but
he
refused.
3.
Sl
Joint pain:
Likely due to the
assault.
May
use
ice/heat, massage: and
Lodine
as
needed, Use
cauliously
given h/o
IBS.
4.
Tonsillar Stones:
May
use
lemon
drops
to
promote
salivation and
remove the
stones
as
they appear
to prevent furtherIssues.
May be seen
by
ENT
for
further eval.• Specialty Referral: ENT
and
psychological counseling eval. Patient
refused
to
be seen
byENT
at
this
time
and
the risks
were
discussed.
Chief
Complaint:
.....
Acute
com
plaint.
History
of
Present
Illness:
Presents today
complaining
of
Nasal
pain
..
Patient
was
involved in an altercation
on 2/26.Duringthe
altercation he
was
assaulted,
punched
in the face,
and
shoved
to
the ground where his head
was
hit into
the
pavement
multiple
times.
During the
altercation,
hehad
a
weapon
as
he
is authorized to carry a firearm
and
he
fired
at the
attacker, killing
him.
He was evaluated by
EMS
and slates his
lacerations were cleaned.
He was
told that
he
had
a
broken nose
anddenies being
taken
to the hospital.
He
then
returned
to work
and
was
told
he
needed a
polleereportand
medicalclearance to return to work.
He
denies HA,
change
in VA, slurred speecl:l, dizziness,
orgait abnormality.
Admits tooccasional
nausea when thinking
about the violence last night, but denies
abdominal
pain.
Also
complaining
of
left
Sl
jointtenderness since
the
event.
Denies
numbness/tingling or incontinence.
Page
1
 
03/09/2012
15:57
To:
attn:
Investigator
Si.
Attn: From: Altamonte Family
Practice
Fax.8304300,
Phone:4073326366
Page
3
of
4
Altamonte Family
Practice
249
MattiandAve
Ste
1
000
Altamonte Springs,
FL
32701
Phone:
407·332-6366
Fax:
407·830·4300
Patient: GEORGE
M
ZIMMERMAN, 28year
old Male,
Race:While,SSN: XXX-XX-9331,
DOB:
10/05/1983
Encounter
Date:
0212712012
11:02
am
.
Encounter Closed
Date:
03/09/2012
03:37pm
Also
concerned
tor
lonsillar stones
that
have been present
tor
many
years.
States
these
become
tender and
bothersome.
OV dominatedby
counseling/coordination of
care
lasting>
25 minutes.
All
data
reviewed
with
the
pt.
FlU care,
referralsand
Ax's
have
been
arranged.
Notes:
P{t
Is
here
for
a
return note
for
work.
Pt
was
in fight on
2/26/12,
pt
was
punched
In
nose
and
has
2
laceration In
theback
of
head.
911
was called
and EMT
said pt•s
nose
was
broken. DV
Active
Medications·
Date!Drug
&
DosageQty
ISIG
RefillNote
02127/2012
Iodine
400
mg
tablet
60
1
tablet PO BID
Oprn
pain
02i13/2012
ladderall
20
mg
tablet
60
1
1ablet
PO
BID
OWritten
Rx Given
P1123t2012
,emazepam
30
mg capsule
90
1
capsule
(hard,
soft,
0
~tc.)PO
HS
P1123/2012
~m
eprazole
dr
40
mg
30
1 capsule,delayed
release
3?RN
!Capsulelienteric
coated)
PO
Daily
12/29/2011
~lbrax
90
1
capsule (hard,
soft,
3
leto.)
PO
TID
Ac
I M
dl
ve
e
cat
ons-
P E I
tl
e-
x s
ng:
Drug
&
Dosage
$tG
pvs
alucosamine chondroitin
tb
1
tablet
PO
Daily
multiplevitamin
tablet
1
tablet
PO
Daily
omeprazole
dr
40
m
g
capsule
1
capsute,delaved
release
(enteric
coated)
PO
DaUv
emazepam
30
mg
capsule
1
capsule (hard, soft,
etc.)
PO
HSReview
of Systems:
Constitutional
Symptoms:
Denies
fevers
and/or
chills.
Eyes:
Denies
loss
and
blurring
of
vision, diplopia.
Ear,
Nose,
Mouth,
Throat:
Admits
nose
pain.Denieshearing loss,
tinnitus.
Cardiovascular:
Deniespalpilalions,
chest
pain/pressure.
Resplrat~ry:
Denies
shortness
of
breath.
Gastrointestinal:
Denies
abdominal
paint
nausea and/or
vomiting.
Integumentary:
Admits-
(Scalp lacerations).
Note
PAN
Neurological:
Admits
head
trauma.
Denies
tingling,
numbness,
weakness,
headache,
dizziness, speech
dirricully,
gaildisturbance, loss
of
consciousness.
Psychiatric:
Admits
stress.
Denies
suicidal thoughts
or
attempts.
Physical Exam:
Page
2

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