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¶
Bureau of Prisons - NYM¶