proportions, which side of history will republicans choose to follow? ♪ >> the federal defense of marriage act unconstitutional. >> the supreme court have not yet arisen to the level of god. >> i'm not evaluating the depth of the right. >> i think there's a new round of culture wars here. >> man and man, wife and wife or man and wife. >> people take it to one extension further, does it have to be human. >> what is it with these people and animals? >> it's a panda, a rare red panda. >> you cannot unsee what you just saw. >> late today, a history-making vote immigration reform passed by a lot. >> it was a good day. >> the louder they scream. >> impossible for the house to ignore. >> we're going to do our own bill. >> you can't limit these people's rights to vote. >> to our friends in the house. >> enough with the house members. >> speak with your votes. >> it's amnesty. >> in a way that you feel comfortable. >> it's sham necessity, sir. >> what is your glitch.

>> it's a slice of ham nessity. it's a slice of vau berry jam e nessity. >> you've been watching the fifth day of witness testimony in the george zimmerman trial. we'll continue to follow the latest developments and bring you updates as we get them. meanwhile, what a week it has been in politics with moment to us events impacting a number of facets of life in this nation, including marriage, voting rights, energy and the environment, national security and the very idea of who can become an american. this time thursday with vice president biden presiding, the senate passed the most significant reform to the nation's immigration laws in a generation. and in the senate chamber, undocumented students known as dreamers erupted in cheers. yes, we can. >> the sergeant at arms will

restore order in the gallery. >> now it's over to the house and speaker john boehner can hardly wait. >> the house is not going to take up and vote on whatever the senate passes. we're going to do our own bill through regular order and it will be legislation that reflects the will of our majority and the will of the american people. >> now, here's hoping boehner and company take a look at our latest nbc polling that shows that 65% of americans favor a path to citizenship if the immigrants had to pay penalties and fines as well as pass a background check and other required steps. hmm, similar to what 68 senators voted for yesterday. speaking of majorities, this week a majority of the justices reflected a view of the majority of americans with a pair of rulings expanding same-sex marriage rights. long-term trend lines show the embrace of same-sex marriage continuing to grow with "new york times"nate silver

projecting only 19 states opposing same-sex marriage by 016. and just six dates all in the south opposing it by 2020. did someone say wrongside of history? >> what we now have today is a holy quintet who goes against the laws of nature and nature's god. >> and a normal family with a mother and a father, that's what's best for children, the supreme court has ignored the needs of children. >> you have five individuals on a court. who have decided it is their morality or immorality, their view of morality or immorality which must prevail. five people. >> that's right. and now that's the supreme court has sanctioned the scandal of government benefits for same sex partners of our military members. it's clear bestiality is the next step "it is difficult because if we have no laws on

this people take it to one extension further. does it have to be humans you know? no, i don't really know, senator paul and if republicans are taking heart in tuesday's supreme court ruling that struck down the key part of the voting rights act allowing voter i.d. laws and restricting efforts to take effect, bloomberg business week joshua green warns, this victory will be a poison chalice for the gop if the stampede to impose new restrictions offends minority voters most affected by the laws who after all are the people republicans desperately need to attract. good thing congress is on recess next week. for some, it's been a rough week indeed. let's get right to our panel. here in new york, msnbc political analyst john alter, and author of the new book "the center holds obama and his enemies." in philadelphia, contributor professor james peterson. thank you both for being with me. >> hi, karen. >> john, i'm going to start with you. so much for a june swoon you

might say. it's been a huge week in washington but it seem like it has been a good week pore republicans in washington. >> well, i think you could make that argument. although if the immigration bill goes through, i would argue that's good not just for the country but for the republican party because they have to do better than 29% of the latino vote which is what romney got in 2012 or they will not be viable as a political party. so they will need a bill, and this is some progress toward that bill. nobody knows for sure what will happen in the house but my sense is the house will pass a bill but the a path to citizenship that's mostly about border security. then it will go to the house senate conference. >> right. >> and a bill will be sent back ta does have a path to citizenship. at that point, a minority of the republicans and the democrats will pass it and by the end of this year, we have not just landmark legislation but legislation that allows the republican party to survive.

>> basically you're saying it could be good for the republicans in spite of themselves based on what we heard from john baner. >> you do have a lot of people in the party from grover norquist to billow rile little. >> to john mccain who's come back around. >>en an half of the gang of 8 are republican. >> that's true. >> there were 68 votes for that bill in the senate. and you know, quite a number were republicans and so there is a chunk of the party that is in touch with reality. it's just the rest of the party. >> professor peterson, the decision on the voting rights some are saying it could help the gop hold onto the house. i felt like josh green of business week argues ultimately it could make the gop more beholden to their white southern base when they desperately need to expand that. i think you could see a repeat of what we've seen previously particularly with among minority voters if we see high turnout. >> yeah, i mean, this is a victory for republicans and

conservatives especially those in washington, d.c. because the evisceration of the vra is going to have a positive impact for a lot of local right wing republican districts. they'll be able to play to their base based on this. we've seen some seven, eight states and municipalities enact different laws, including i've heard rumors of a poll tax being instituted. voter i.d. laws being in process. the whom jenization of the republican party. the only future for the party is to become more diverse. vra does not help this em with that. at the end of the day, you have to question the logic of the ways in which they continue to play to the shrinking minority of the base of the republican party. it doesn't seem to make much political sense but at the end of the day, that esa local tension -- there's tension between the local and the national and the local folk are going to end up doing better with the vp ra craziness going on right now as we speak than some of the national politicals

in the republican party. >> you know, john, it strikes me if we see -- i mean agree with dr. peterson on one hand but on the other hand, if we see a repeat of the last couple of election cycles where the inevitable demographic changes of had country come to bear and you see more minorities voting, latino, african-american and women, let's put them in there too, that actually means that the gop is overly dependent on a base that is not necessarily going to be able to balance out sort of these larger numbers of turnout, right? >> you can set your watch to the idea that every four years, the percentage of the electorate that's white is reduced by between 2 and 3% for the last 25 years. and so for mitt romney to have won then election, he would have needed the same percentage of the white vote that ronald reagan got in the 1984 when he carried 49 states. >> right. >> that's an awfully high bar to say that in order to win with white votes, we have to get up

to ronald reagan's levels? >> that's not a path to victory in presidential elections. they'll do well in midterms. a lot of minorities don't vote in midterms. that's just the reality. in presidential elections we've seen in the last two, the new obama coalition turns out in droves, 125, 130 million americans, and it will be very, very difficult for the republicans to compete until they start trying to appeal to them. and they can do that. >> repel. >> once immigration reform is off the table, if that's signed even though obama gets most of the credit, it does allow the republicans to compete for those votes, but if they block immigration reform, they are in deep trouble for a long time in this country. >> you know, professor peterson, we were all focused on immigration in the courts but there was also a deal to employee vent student rates from doubling on monday. and that's a real burden on millions of students and families. can we hope perhaps something is going to get done on this after

the fourth of july. >> i'm not hopeful at all what this congress can and will do. what i will say is as a nation, we've got to understand what the value is of college education. we've got to he reinstill in the national and public discourse what the value is of a collegiate education. i think then it will make more sense to make it more affordable and accessible for young people. it's interesting how all these these things are interlocking because the demographic most interested in making sure college is affordable and accessible is the same demographic the republican party is turning its back on on all these rulings that are an you loing them to disenchance fries voters. >> james, if the republicans get into a position where they are the ones who are blamed for a doubling of college loans, that's a very good issue for democrats in the 2014 midterms. >> i feel like the list of issues good for democrats seem to be piling you. . jonathan alter, professor james peterson, thanks to you both.

there's been a brief pause in the george zimmerman trial. the jury left the room while attorneys debate a piece of evidence. we'll go back when the testimony resumes. we'll be right back in just a moment. alec, for this mission i upgraded your smart phone. ♪ right. but the most important feature of all is... the capital one purchase eraser. i can redeem the double miles i earned with my venture card to erase recent travel purchases. and with a few clicks, this mission never happened. uh, what's this button do? [ electricity zaps ] ♪ you requested backup? yes. yes i did. what's in your wallet?

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bulldog: that's a ringer of a deal! radio: mattress discounters' 4th of july sale ends soon. ♪ mattress discounters this fifth day of testimony in the george zimmerman trial continues right now. so far it's been a week of dramatic and at times emotional testimony. we're going to get to the legal analyst lisa bloom closely monitoring the trial with us. also with us is goldie taylor. i'm going to start with you, lisa. so we see the jury has left the courtroom and lease apparently a debate among the lawyers. tell us what's going on right now. >> the attorneys are at sidebar arguing about the admissability of george zimmerman's medical records from a visit he made to a physician's assistant the day after the trial. >> so why is that will relevant

in the case? >> because george zimmerman's injuries or lack thereof are a big topic in interest this trial. the prosecution claims his injuries are not serious. he suffered a couple of cuts. that's about it. it was not a life-threatening fight or situation at the time that he shot trayvon mar pin. the defense put up photos over and over again today to show there were a couple of lacerations on the back of his head, that his nose appears to have been broken and that is it was bleeding. depending on which side you know is giving their argument, he was either pretty injured or not all that injured. >> also i remember initially in this case, one of the questions that people had was whether or not he really had been injured or whether or not perhaps had he injured himself after the fact to be consistent with the story that he told. i would imagine that's part of why this is so crucial for the defense yeah, and i should say that the idea of self-inflicted injuries has not come into this trial at all. in fact, we've got a pretty tight timeline than just after

the gunshots a witness came running out within a pat matter of probably seconds and saw him. police officers also arrived on the scene very, very quickly. on the other hand, there isn't blood on the sidewalk and he claims that is trayvon martin was banging his head on the sidewalk. so it's a case about physical evidence and this is just the beginning of getting into the medical injuries. >> you know, speaking of jonathaned neighbor who served the fight, he testified as he you mentioned earlier today. he was actually called by the state, but it was suggested that it may have been mr. -- he suggested it may have been mr. martin who was in control during that confrontation. so did his testimony end up, was it more beneficial to the state or to the defense. >> definitely more beneficial to the defense. and this is a good defense team. they've turned a number of prosecution witnesses. the prosecution has the obligation to support the youth truth in this trial. they need to bring in all of the witnesses really who have something relevant to say because if they don't, the defense will call those

witnesses and imply that the prosecution is hiding them all if they haven't given the injury the full story. bet are for the prosecution to take a witness they know is not good for them, put them on the stand, have them give the testimony and try to limit it, try to bracket it as best they can. mr. goode said ta trayvon martin was on night fight in the fight. zimmerman was calling for help and trayvon martin was punching him mma style just before the gun went off. >> there was a reference to pound the ground and a television show which i taught was interesting given that earlier this week when rachel jeantel mentioned she had been watching the first 48. there seemed to be skepticism about getting that kind i have information from a television show. i found that to be an interesting distinction. >> this is the way real people talk. i mean, this is not a tv show. this is a courtroom and people bring their experiences too it, and a lot of people make references to tv shows in a

trial. that's not unusual. >> goldie, rachel jeantel was a key witness earlier this week and described the phone call she had with mr. martin before his confrontation with mr. zimmerman. the defense was attempting to discredit her. in your opinion, do you think they were successful in doing so? >> i'm not sure they were. if i'm a defense attorney and i've got a person on the stand, then i want to make sure that i am able to impeach their credibility at nearly every level. and it seems as though some of the statements that miss jean tell said were not true. we was not 16. she did not give sybrina fulton her real name. and she had some very plausible speaking from her culture, a very plausible reason as to why not to tell the truth in those situations. was she, however, consistent in that she believed trayvon not to be the aggressor? was she consistent in that trayvon was near his father's

house and simply trying to get away from george zimmerman? >> he was absolutely consistent in those things and there was nothing that don west did to underkuta credibility. so some of the moral unfortunate advice voices we've heard online and we've even heard across other networks that are assailing rachel jeantel as somenaire do well who is less than intelligent who may be less than beautiful, who may be larger than you know a woman you might want to be, i just think that that is just very, very unfortunate. we can't choose our witnesses. she was the last person who spoke to trayvon martin that night. she has as much credibility as a p.h.d. on the strand right now. >> she came off to me as being very sincere in explaining the reasons she gave as to why she said something different previously. they seem from our cultural lens from, her experience, it seemed very plausible to me.

she seemed very credible and very sincere to me. what effect if any do you think that will have on the jury which part of the conversation we've been having this week is the jury comes from a different cultural lens. >> absolutely. i think therein lies the issue. the only thing that matters, it doesn't matter how we see rachel jeantel. it matters how the jury sees her, how the jury sees this evidence. we have five women on that jury who may or may not share the same kind of cultural background that rachel jeantel does. i think that that's going to whether or not the prosecution can really help them make that connection will be the rice and fall of this case. but there is so much more evidence to be brought to bear. and there's another piece of information that i've been thinking about all day today and talking about it on social networks. are we seeing the same george zimmerman in court now astray von martin encountered that

fight? >> yep. >> he is 100 pounds heavier. is he clean shaven. he no longer is this buff tan guy with a goatee that to me is simply more improposing. i'm not sure if i saw this george zimmerman at night confronting me that i would feel nearly as intimidated as the george zimmerman we've seen in some of these photographs. i wonder if that weight gain has something to do with the stress and pressure of being under house arrest. i wonder about that weight gain has something to do with a concerted effort by the defense to make sure their client appears as nonthreatening as possible. you know, those are all of the things in the tool kit that the defense has to work with. and i think we've got to seep these two menace they saw each other that night. >> you know, lisa, i want to get your take on that point because that was actually something that occurred to me as well as when we first started seeing this george zimmerman over the last couple of weeks. he does look heavier.

he doesn't look sort of like the tough strong guy who could have taken on trayvon martin that we saw initially in the case. does that have any bearing? i mean, is it a tactic of the defense to try to fatten him up a little bit if you will? >> good point. i've mulled that over myself. the fak that he's put on about 100 pounds since this accident, you could look at it well he's a bigger bull cannyer guy and perhaps more intimidating than he was when he was much smaller. on the other hand, the defense said that because of the stress of the case, he's put on a lot of weight. of course, defendants are always going to come into court in a suit and tie, well groomed, he's grown his hair out. it was almost shaved to the head from some of those photos afterwards. i'm not going to say he put on this weight intentionally to look better at the trial. we don't have evidence to substantiate that. >> he doesn't look like the same kind i have person who you could argue would take on a young teenager. but we'll see. we're going to take a quick

break and we will go back inside the courtroom when the testimony resumes and we'll be back just in a moment. every day we're working to be an even better company -

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nbc's carrie sanders has been monitoring the trial all day long and joins us now from sanford, florida. give us a sense, we've been so focused what's going on inside the courtroom. give us a sense what's going on outside the courthouse with the crowds and the people who are gathered there. >> you know, actually the crowd's never really materialized here. it's 97 degrees outside. so that probably has a lot to do with it. we have the afternoon thunderstorms. and while they set up a little protest area or a demonstration area outside the courthouse anticipating that people may want to exercise their free speech, they actually don't have the ability to use speakers or hold umbrellas and so most of those who thought that they might come down here said they felt it was a little restricted. remember, when this first happened, most of those who were demonstrating protesters said it is that they wanted a fair

shake, specifically trayvon martin's family said they wanted their day in court. sosa brin na fulton and tracie martin, the parents of trayvon martin have said they achieved what they wanted, their day in court. it's now moving forward. we're at the end basically of the first week. the beginning of the week, we had opening statements and then some people felt that the defense put on a rather odd opening statements with knock knock jokes and everything else. then we've been listening to the system from witnesses and establishing certain fakes, remember, it may seem odd but they have to establish that be trayvon martin died. so they had to bring in a police officer to say indeed there was the young man who was there at that location. even though george zimmerman has admitted that he shot and killed 17-year-old trayvon martin. so we're hearing from that. what we're likely to see is probably in the next half hour

to an hour the conclusion of a week's worth of opening statements and testimony. now the jury, an six-member jury down to three alternates. they're sequestered. they'll go to their hotel and have a weekend together. the court will put on activities for them if they want to participate in them but they won't be allowed to talk about the case. they he aren't allowed to. they can't go on the internet or research anything. >> i want to bring in lisa bloom still with us. i see the witness has now gone back to the stand. so do we think that means they've reached some agreement with regard to this evidence that they were discussing? >> well, i would assume that the judge made a ruling in that sidebar. we won't know what it is till the testimony resumes. this is lind zee full gate the physician's assistant who examined george zimmerman the day after the shooting. >> to the point lisa was mentioning about the knock knock joke, is that the kind of thing that's going to stay with the jury and sort of color their

impression of that defense attorney as he proceeds throughout this case or something people can let go and focus on the evidence? >> i don't think the jury is going to make too much of it. it was unfortunate at the time. he apologized. they've been listening to a lot of very important evidence in the case. i think they're going to base their decision on that. >> you know, kerry, tell us a little bit about, you were mentioning that the injury obviously, they will be sequestered over the weekend. what's this week been like for them? it's been a pretty intense first week of this trial. >> it's kind of like i guess a student going to school where everything is you go here, you go there and you're following orders. they are told where to be, when to be. their lunches are served. usually at around noontime. the judge has done her best to give them an hour today. she gave them 90 minutes. they broke before lunch even arrived here. but their life is extremely structured. and for some people, that's great. for others, they like the freedom to be able to do what

they want to do. i've spoken to be jurors who have been sequestered on other cases who tell me that it's a little bit like feeling that maybe you're the prisoner and it's not a very comfortable feeling. and this jury is going to be sequestered. it appears if we look at the potential schedule here for about three weeks. it looks like next week we might get into more forensic evidence and the state will wrap up its case and the defense will present its rebuttal to the evidence presented by the state. so the general sense from some of the attorneys who were actually in the courtroom is that this will be in total, the trial will be three weeks. we're not talking about jury selection. we probably have two more weeks to go before the jury can begin sort of looking at the evidence and deciding whether they think there is guilt, not guilt, or remember that other possibility, a hung jury. >> you know, lisa, to this point about the evidence, one of the things in watching this trial is that you know, it's a very meticulous walk through what

happened, what the evidence is. and a lot of it honestly feels very redundant for those of us watching. i'm assuming most of that is really for the benefit of the jury to make sure that points are made and underscored and underscored again because this is it. right? the jury if they have questions, they have to go back and refer to the testimony so they got to get it in right now. >> this is a real trial. this is not a tv show or a movie where it's truncated, where trial lawyers like me roll our eyes and say yeah, that's not how it goes. we have witness after witness who tells their story on cross-examination. they can be made to tell the story all over again in ex-cruciating detail because the defense is trying to find inconsistencies in their testimony. as laborious as cross-examination can be, it's the best system we have come up with to get to the truth because people who are telling lies tend to be inconsistent when they tell the story over and over again. so they can be made to do that, to compare their prior stories

to what they're saying in court. the defense attorney can comment upon it. also some witnesses may not be believed so on important points, the prosecution can put on multiple witnesses to establish the same point to make sure that they can prove their case beyond a reasonable doubt. the prosecution has the burden of proof. it's a tough burden in a criminal case. the highest burden we have in our legal system beyond a reasonable doubt. they have to put on multiple witnesses sometimes to establish a point. >> just before the court adjourned yesterday, there was an issue of mr. zimmerman's prairie straining order that was raised. has that been resolved or still undecided? >> i have not heard a ruling on that yet. i agree with you. that is a really interesting point. and i was surprised when mark o'mara on the cross-examination of a witness yesterday elicited testimony that will george zimmerman was not a hot head, that he was a calm person in general. that he was a likable person because now we're getting into his character and background. and dozen that open the door for

his prairie straining order. >> and this whole -- we are going to listen into the proceedings now. the jury's come back into the courtroom. let's lis. >> and with you having mr. zimmerman the defendant as a prior patient as a patient back income first contact with him would have been august 19th, 2011, is that correct? >> correct. >> as part of your contact with the defendant ta day, you obtained a history from the defendant, is that correct? >> correct. >> okay. and when you obtained a history you actually spoke to him yourself? >> correct. they come in with a prefilled out history that they bring with hem so we have some sort of idea of what their history may be and then we take the rest of it. >> i'm going to show you what's been marked introduced into evidence as stibt 195. may i approach the witness urn? >> yes, you may. >> and do you recognize that exhibit as part of the medical records that are kept at your family practice altamonte family

practice. >> yes. >> i've highlighted certain parts that i want to ask you specifically about. if you can make reference to those. >> okay. >> that will record would indicate that he was a patient of yours and it's got his name, george m. zimmerman, 27 years old, male, race white. is that correct? >> correct. >> it would have the encounter date august 19th,ing 2011 at 1:29 p.m. >> correct. >> in terms of the highlighted parts only, can you read the first part, are the first snchbts highlighted part? >> of the history of present illness. >> yeah, just the highlighted part only. >> seen in the office to establish care. referred through insurance provider. >> in that will same paragraph, it also has a highlighted part towards the bottom of that paragraph. do you see that? >> yes. difficulty with falling and maintaining sleep. started to exercise intensely with mma. but this has not helped. >> i'm sorry, with can you repeat that the last sentence? >> difficulty with falling and

maintaining sleep. started to exercise intensely with mma but this has not helped. >> and were you able to determine mma is being mixed martial arts? >> yes. >> on the notes i believe there are two sentences that are highlighted. is that correct, in yellow? >> yes. >> and could you read those two sentences? >> patient here to establish care. patient was referred by his insurance list of providers. mam ma'am, i'm going to now provide to you with the court's. er mission, may i an prop the witness your honor. >> yes you may. >> a date which is september 23rd of 2012, and i'm going to show you state's exhibit 196. . >> that's 2011. >> i apologize.

that's 2011. thank you, your honor. >> do you see that exhibit before you, ma'am. >> i do. >> your treatment -- i'm sorry. you would have had contact with the defendant again george zimmerman on that day? >> correct. >> question you say contact, you yourself actually had contact with the defendant? >> yes. >> okay. >> on ta day also, when you saw him, you gathered just -- it's got that exhibit's got the regular information, george m. zimmerman, 27 years old, male, white, and the date september 23rd, 2011 at 1:52:00 p.m. is that correct? >> correct. >> and i believe there's a highlighted part on that page where you've got in terms of social history exercise. is that correct? >> correct. >> and what did you notate there in terms of social history of exercise as to the defendant george zimmerman? >> that he was involved in mixed martial arts three days per week. >> may i approach the witness, your honor? >> yes, you may.

>> let me show you state's exhibit 194. you would have seen him on -- >> so on the stand now we have physician's assistant lind zeal

folgate, she is talking about the injuries george zimmerman had sustained based on her examination of him. i'm going to bring lis za bloom back in with me on this one. we were talking about this earlier in the hour about the nature of zimmerman's injuries. do they back up his version of events, do they contradict his version of events. i assume that is why they are having her so meticulously again as we were just talking about kind of going through the nature of the injuries, the nature of sort of her encounter with him and the sort of questions that she asked during that encounter. >> yes, and let me add one more thing. it's really interesting that just now, the testimony was that he had started to exercise with mma. >> yes. >> mixed martial arts. why is that important? because we heard from a witness earlier in the dha there was one man on top of the other man engaging in pound and ground mma

style. now, that witness said trayvon martin was on the top. george dim isser man was on the bottom but he couldn't be 100% sure. so to hear this physician's assistant say in the very same day of testimony that george zimmerman was taking mma three times a week has to be grabbing the attacks of the jury. >> we're having a technical issue with the pool feed out of the courtroom. lisa, to that point, i had the same thought. i noticed that the prosecutor had her -- she said mma and he said repeat that? >> he really underscored, so are we now saying so both guys knew mma so it's a wash? >> we don't have any evidence in the trial yet that trayvon martin did. this is the first evidence in the trial, i want to emphasize the trial and that's what the jury has to base their decision on that anybody knew mma and that it was george zimmerman. that's what they're hearing so far. i also want to take you that's a

very common lawyer trick. i'm sorry, i didn't hear you. could you peept that? did you say mma and act surprised and hard of hearing to get people to repeat a good point. >> we've got the feed back so we're going to go into the courtroom and watch the proceedings. >> i'm assuming vital signs would have been taken first? >> yes. >> and then the next part would have been patient is here for whatever and patient states something. is that correct? >> correct. >> okay. and if you could, i think that's on page 2 of those records? >> uh-huh. >> patient is here for what? go ahead and tell us. >> patient is here for a return note for work. patient was in fight on 2/26/2012. patient was punched in nose and has two lacerations in the back of head. 911 was called and emt said patient's nose was broken. >> i gather when we're talking about right here notes, this is what mr. zimmerman is telling the medical assistant?

>> correct. >> okay. so he's telling the medical assistant that he's there for return. >> correct. >> that he was in a fight on september ept -- i'm sorry, on february the 26th of 2012. that he was punched in the nose and has two lacerations in the back of the head. that will 911 was called and an emt said his nose was broken. >> correct. >> is that correct? >> uh-huh. >> and then you would have reviewed that and then actually had contact with mr. zimmerman? >> correct. >> okay. so i think we now go to the -- i've got it as the front page. would that be history of present illness? >> that is where i would begin. >> so you would have had contact with him at ta time? >> correct. >> and i gather you talked to him. he tells you what his ailment is and then you would have treated had im. >> correct. >> if you could, tell us at that time when you're talking to him what he tells you. >> when we are talking during that time, basically what i've written in the note is what he

is telling me. and that states that he was involved in an altercation. he was assaulted. he was punched in the face and shoved to the ground where his head was hit into the pavement multiple times. he then proceeds to say during the altercation, he had a weapon that he was authorized to carry a firearm and he fired at the attacker killing him. he goes on to mention that he was evaluated by ems at the scene. and he states his lacerations were cleaned during that time. he was told that he had a broken nose and denies being taken to the hospital. he then returned to work and was told he needed a police report and medical clearance to return to work. and then i go into my review of systems and asking him certain questions that he would confirm or deny. >> so you first get his statement as to what happened or why he's there. >> correct. >> okay. and i think the first part is he states today he's complaining of nasal pain. >> correct. >> nasal pain would be his nose. >> correct. >> okay. and then he tells you the history and then you then diagnosis what, do you go over

all the parts of his body or what do you do? >> after we discuss the history, i ask certain questions which we clarify as our review of systems which would be on the following page. >> okay. >> once we go over the review of systems, i'm basically asking him to confirm or deny certain symptoms that he may be having at the time and then i move onto the physical examination which is where i determine what will injuries were noted and then based off of that, what would need to be treated. >> so let's go back a second and then talk about review of symptoms. go ahead and cover those, please. >> okay. so during the history of present illness, i again asked him if he was having any headaches, change in visual acute, slurred speech, dizziness or gait abnorm malt and then i also asked him, what is he having any nausea or vomiting and associated with that any abdominal pain. i then go through and look at the review of systems as well as this is a dropdown box menu in our electronic medical system and review any other symptoms that may have been involved.

>> all right. so let's take those one by one. >> okay. >> in terms of you asking him, he denied ha, what does that mean. >> means headache. >> so he denies having any headache. >> correct. >> change in ba. what does that mean. >> va means visual acute. so no change in vision sbug. >> he denies any slurred speech. what does that mean? >> that would mean exactly what it says, but any slurred speech and sometimes rephrase that to patients as are you talking any more abnormal than what you would have normally. >> he denied dizziness. that's an obvious one but let's make sure for the record what that means. >> clarifying to see if he had any dizziness, off balance for any reason. >> gait abnormality meaning he's able to walk fine? >> exactly. sometimes i'll clarify that in layman's terms meaning are you walking as if you were drunk or staggering. >> then i notate on the history of present illness he admits to

occasional nausea when thinking about the violence last night but denies abdominal pain. >> he was telling me when he was reflecting on what happened that night that he was having some nauseous feelings and i would then further ask, are you having abdominal pain to clarify whether the nausea was coming gr abdominal pain symptom or a psychological factor. >> what was your determination? >> that was more from a psychological factor. >> you notate complaint left si joint tenderness since the event. go ahead and tell house that means. >> the si joint is the sacroiliac joint and he has mentioned that he was having some tenderness on left side since the altercation that night. >> and you also notated he denies numbness or tingling or incontinence. >> these are follow-up questions i would ask on anyone who complains of back pain to make sure there was nothing more severe going on. was he having any numbness or

tingling in his extremities or ball bowel or bladder incontinence. >> when you say drop down or you're going through in terms of constitutional symptoms, right? he denies fevers or chills. >> correct. >> his eyes, he doesn't have blurred vision or. >> diploplia means double vision. >> ears, nose, mouth and throat. tell us about that. >> he admits to nose pain but has no hearing loss or tin nighttis which is ringing in the ears. >> what's the significance of that. tell us about that. what are you looking for. >> the significant of the tinnitis? just making sure the trauma he is telling me he sustained would there be any significant side effects from that and one of the ruls could be hearing loss or ringing in the ears. >> he has no ringing in the ears or hearing loss. >> no complaints of that. >> that's all you can go on? >> correct. >> but you've got in here admits nose pain. i think we're going to get to

this in a little while. is that correct? >> correct. >> cardiovascular. tell us about that. >> he denies palpitations meaning any abnormal irregular heart beats and he denies any chest pain or pressure. >> respiratory. >> denies any shortness of breath. >> okay. tell us about the next few other ones. >> the gastrointestinal, denies abdominal pain, nausea and or vomiting. related to the gastrointestinal system. >> okay. >> the skin, i put in there admits scalp lacerations because that is one of his concerns. neurological would be next. admits to head trauma as he's telling me he sustained head trauma might based on the story he's telling me but denies headache, dizziness, speech difficulty, gait disturbance or loss of consciousness. then the last part would be psychiatric. he admits to stress surrounding the event but denies suicidal thoughts or attempts. >> go back to neurological in

terms of admits head trauma. why are you concerned about whether he has difficulty wist speech or he's got headaches or whether he's lost conniousness. >> the significance of those symptoms would be more concerning or lead me to down another line of questioning and that would further potentate the certain treatment that i would elicit. >> the i'm sorry. i interrupted you. you have no concerns in terms of he says he's not losing consciousness. he's able to function fine. he has no problem in terms of concentration or weakness or headaches or anything like thatting? >> correct. >> okay. >> if he had complained of those, what steps would you have akin in treating those? >> it would be based off my physical exam so i would take those symptoms into consideration while i'm doing the physical exam and you would rank those uncertain severitity, then you would proceed with

possible imaging, meaning a picture of the brain. >> so at this point, you had no concern about -- we're going to get to the physical. you have no concern regarding that? >> based on what he's telling me, there is less concern, correct. >> all right. i guess we then, am i skipping a step or are you going now to fiscal exam. >> the physical exam. >> cover that please. thank you. >> no problem. so the first part of the physical exam would be his general appearance. it says he's in no acute distress. most of the time that means is he any physical shortness of breath or significant pain at the time. is he obese and that's based off his body mass index which takes into account his height and weight. >> let me interrupt you. i apologize. is his height and weight anywhere on here? >> on the first page. >> i neglected to ask you about that. >> in the vital signs saying he's 5.75 inches and weighs 204. >> 5'5".and how much?

>> 7.5. >> what was his weight? >> 204 pounds. >> i apologize. i interpreted you. you stated also he is obese. that is based on what now. >> based off his body mass index which takes into your height and weight. a bmi falls into the category of obesity. he is alert and oriented and appears his stated age. >> anything significant with that? >> i would take that into account given the history of the head trauma to make sure he's alert and is understanding the questions i'm asking him. >> go ahead. >> next would be head. he's normocephalic. the face is symmetric. two scalp lacerations to the occiput, the back part of the head approximately 2 centimeters and 0.5 centimeters respectively. >> tell me the significance of

that. >> the significance of the measurement itself? >> yes, you used some big words there. tell me what you mean by those big words. >> the significant would be two lacerations meaning two cuts to the back of his head and the occiput is the back part of the head. i measure them given his concerns and his complaints to have that documented to make sure that we know should these not heal appropriately, these were the original size that he came in to be seen for. >> you said two centimeters and 5 centimeters. what is that inches i guess? or can you estimate using your finger i guess or using your -- how small are they? >> two centimeters would approximately be about this big and 0.5 is much smaller. >> based on your observations and review of those lacerations, did you feel there was anything additional that needed to be done regarding those?

like any kind of stitches or anything like that? >> that determination is based on how well the skin edges what we call approximated which means how well are they together to begin with and how deep is the laceration itself. based off of the of approximation of the skin margins and the depth of the lacerations i did not feel that sutures were necessary. >> and a laceration, tell us what that means when you say a laceration versus a cut or something like that. >> a laceration is basically a more proper term for a cut. >> okay. and you said it wasn't deep enough to require, in your opinion, any stitches or anything. is that correct? >> correct. >> and you said the skin edges were approximately well, if i've got that right? >> correct. >> tell me about the eyes. >> eyes it says perrla, which pupils are equal, rounden an recan antive to light and the extra ocular movements are intact so i'm checking his

pupils to make sure they're responding to light inappropriately and we check the extra ocular move ps meaning how well are his eyes moving in each direction and that was normal. it says con jung tiva and sclera were clear. making sure there's no ingualeekz that part. but i did note that he had bilateral black eyes. >> what does that mean to you? >> that would mean skin discoloration to the inferior orbit meaning the bottom portion of the eyes. >> going back to the head to i guess the scalp, you noticed those lacerations, did you notice any other trauma to the head at all? >> i did not at the time. i don't recall. >> let's talk about the ears, nose, mouth and throat. >> bruising noted to the nasolabial folds bilateral with swelling. the nasolabial folds would be the folds between the nose and the mouth and there was some

swelling note there had. and some bruising so darkening of the skin. no evidence of septal debiation on visual inspection meaning the center part of your nose appeared to be straight and in alignment. no bleeding noted in the nares. there was no blood in the nose itself. nom hemomole temp poe anyone to the bilateral ears which means there's no blood behind the eardrums and no evidence oftoncy lar stones which was a complaint that he had outside of the current reason that he was there. >> so let's talk about the nose itself. no evidence of accept the deviation. >> septal deviation again would mean is the alignment of the nose correct. >> so his nose is straight in other words. >> correct. >> it is not crooked or in any way damaged to that extent. >> not on visual inspection, no. >> okay. >>. >> i think you've already covered the chest and his heart he said or everything else seemed norm? >> correct.

>> you talked about tender left si. correct? >> correct. >> okay. and tell me a little bit about that again. >> the si again is the sacroiliac joint. which is the space located for lack of a better word in the center of your buttocks. >> i think you gave him some medicine for the complaint he had. is that correct? >> for the si joint pain, correct. >> yes. what did you give him. >> we gave him lodine, which is an anti-inflammatory. >> by the way, when you saw him regarding those lacerations did he have nel band-aids or anything covering them? >> he did have one large band-aid covering them. >> i'm assuming, did you remove the band-aid to look at them? >> correct. >> you mentioned that he said that mr. zimmerman told you that the emt had told you the nose was either broken or possibly

broken. >> that was what i was told, correct. >> based on your examination of his nose, can you say that his nose was broken? >> i would say likely broken. it's hard to say definitively based off the fact that there were no x-rays to show the break itself. however, most of the time a broken nose can be made clinic little, as well. that's based off of the black eyes we saw the nasolabial swelling, the bruising. >> so you can say it is or it isn't or you don't know or. >> i couldn't say definitively one way or the other because i have no direct x-ray saying this is exactly where the fracture occurs. but clinically appearing, it appeared to be, yes. >> okay. but it was still perfectly straight? >> it was still straight. there was no septal deviation.

>>. >> i think you've got in terms of the plan decision making progress, is that what you would move on to next. >> after the physical exam, yes, i would move to the plan and the decision making process. >> you talked about the scalp lacerations that there was no sutures needed. in other words, are he didn't need anything sewn up at all, correct? >> no stitches, correct. >> and you stated in terms of broken nose that we discussed it is likely broken but does not appear to have september.deviation. swelling and black eyes are typical of this injury, correct? >> correct. >>. >> now, you're there. did you then recommend something to him in terms of making the definitive determination of whether his nose is broken or whether there would be any problems regarding that. >> my recommendation is he see an ent, ear nose and throat

specialist. >> what did you say regarding that. >> he told me at the time that he was not going to go to be seen by the ent. >> rd raing the si joint pain, did you give him some suggestions? >> we discussed using the lodine, which is the anti-and the inflammatory to help with the inflammation and we discussed heat, ice and massage. >> sl >> you had seen him the three times we covered here, but you had seen him at other times. he had complained on a prior occasion of having some back pain? do you recall ta? >> i do. >> had you treated had i am for that before? >> i had. it was related to constipation. >> so it was not related to his

injury itself like a physical injury? >> correct. >> if i may have a moment, your honor. >> yes, you may. oh, i apologize. in terms of laceration to the head, you mentioned two of them. >> uh-huh. >> i got a bald head head. so i know what it is to get cut or have a laceration. how do those bleed and distinguishing that from a cut somewhere else on the body? in terms of, is there something with the head the fact that it bleeds more profusely or does it? tell me about that. >> the scalp is very vascular. meaning it has many blood vessels there. so a scalp laceration can bleed quite a significant amount more than perhaps somewhere else on the body depending on location. >> how about a person doesn't have any hair in. >> it doesn't necessarily mean it will bleed less but maybe less noticeable because there would be maybe some hair blocking that area. >> in other words, if you have hair, it would be either have

more of an impact of cushion or you won't notice? >> possibly both. you may not notice the amount of blood because it could be getting mixed up with the hair itself. and i guess it would depend on the thickness of your hair to depend on the amount of cushion that would be -- >> i have no further questions at this time. thank you. >> thank you. mr. o'mara. >> yes, thank you. if i might. >> i will need a little assistance. recruit you for a moment.