EFTA00059534

Bureau of Prisons
Health Services
Clinical Encounter

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/30/2019 15:58
Provider: MD
Reg #: 76318-054
Facility: NYM
Unit: Z01

Chronic Care - Chronic Care Clinic encounter performed at Health Services.

SUBJECTIVE:

COMPLAINT 1 Provider: MD

Chief Complaint: Other Problem

Subjective: PATIENT WAS REFERRED BY THE WARDEN FOR EVALUATION.
PATIENT REPORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE AGGREES REPORTS NURBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO.
STATES THE NUMBNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING.
HE DENIES RIGHT SIDED WEAKNESS, DIAPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OR SWALLOWING.
HE REPORTS NOCTURIA OF ABOUT 5 TIMES., HE DENIES DYSURIA.
HE REPORTS H OF KIDNEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL.
HE ARE A HX OF SLEEP APNEA AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HAS EEN HERE SINCE HE DIE NOT HAVE ACCESS 7 TH CPAP MACHINE. I INFORME DHIM THAT WE RECERVED HIS CPAP MACHINE AND 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, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely Ill

Nutrition
No: Appears Obese

Pulmonary

Auscultation
Yes: Clear to Auscultation

Cardiovascular

Auscultation
Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2
No: M/R/G

Musculoskeletal

Tibia / Fibula
No: Edema

Neurologic

Generated 07/30/2019 16:12 by MD Bureau of Prisons - NYM

EFTA00059535

## Exam:

Cranial Nerves (CN)
Yes: Within Normal Limits

Motor System-General
Yes: Normal Exam

Motor System-Strength
Yes: Normal Muscular Strength

## ASSESSMENT:

Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current

Constipation, unspecified, K5900 - Current

Essential (primary) hypertension, I10 - Current - BYHX.

Hyperflipidemia, unspecified, E785 - Current

Low back pain, M545 - Current

Neuralgia and neuritis, unspecified, M792 - Current

Prediabetes, R7303 - Current

Sleep apnea, G4730 - Current

## PLAN:

### New Medication Orders:

**Rx#** | **Medication** | **Order Date** | **Prescriber Order**
---|---|---|---
INsulin REG - Human | | 07/30/2019 15:58 | SLIDING SCALE
Subcutaneously each morning x 7 days) Pill Line Only

### Discontinued Medication Orders:

**Rx#** | **Medication** | **Order Date** | **Prescriber Order**
**122148-NYM** | Insulin Reg (10 ML) 100 UNITS/ML Inj | 07/30/2019 15:58 |Inject regular insulin subcutaneously per sliding scale: twice daily ***pill line*** for 7 days

### Discontinue Type:
When Pharmacy Processes

### Discontinue Reason:
new order written

### Indication:

### Copay Required:
No

### Cosign Required:
No

### Telephone/Verbal Order:
No

### Completed by:
MD on 07/30/2019 16:12

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*Bureau of Prisons - NYM*