EFTA00073839

# Bureau of Prisons Health Services Clinical Encounter

| Inmate Name: | EPSTEIN, JEFFREY EDWARD |
| :--- | :--- |
| Date of Birth: | 01/20/1953 |
| Encounter Date: | 07/30/2019 11:12 |

| Sex: | M | Race: WHITE |
| :--- | :--- | :--- |
| Provider: | | |

Reg #: 76318-054
Facility: NYM
Unit: Z01

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

## SUBJECTIVE:



COMPLAINT 1 Provider:


Chief Complaint: Other Problem

<table><tr><td>Subjective:</td><td>PATIENT WAS REFERRED BY THE WARDEN FOR EVALUATION.

PATIENT REPORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO REPORTS NUMBNESS 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, DIPLOPIA, 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 AHS A HX OF SLEEP APNEA AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HERE SINCE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE RECEIVED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT..

HE REPORT OTHER NON-MEDICAL ISSUES.

STATES HE FEELS OTHERWISE FINE.</td></tr><tr><td>Pain:</td><td>Not Applicable Withheld pursuant to exemption</td></tr></table>

**Seen for clinic(s):** Endocrine/Lipid, Orthopedic/Rheumatology, Pulmonary/Respiratory

(b)(6); (b)(7)(A); (b)(7)(C)

OBJECTIVE:
of the Freedom of Information and Privacy Act

Pulse:

| Date | Time | Rate Per Minute | Location | Rhythm | Provider |
| :--- | :--- | :--- | :--- | :--- | :--- |
| 07/30/2019 | 13:02 | 94 | | | Beaudouin, Robert MD |
| 07/30/2019 | 09:40 | 88 | Via Machine | | Beaudouin, Robert MD |
| 07/30/2019 | 09:30 | 87 | Via Machine | | Beaudouin, Robert MD |

Respirations:

| Date | Time | Rate Per Minute | Provider |
| :--- | :--- | :--- | :--- |
| 07/30/2019 | 09:30 NYM | 12 | |

Blood Pressure:

| Date | Time | Value | Location | Position | Cuff Size | Provider |
| :--- | :--- | :--- | :--- | :--- | :--- | :--- |
| 07/30/2019 | 13:02 NYM | 114/84 | Left Arm | Standing | | |
| 07/30/2019 | 09:40 NYM | 125/60 | Right Arm | Standing | | |
| 07/30/2019 | 09:30 NYM | 108/86 | Left Arm | Sitting | | |

SaO2:

| Date | Time | Value(%) | Air | Provider |
| :--- | :--- | :--- | :--- | :--- |
| 07/30/2019 | 09:30 NYM | 98 | Room Air | | |

Weight:

| Date | Time | Lbs | Kg | Waist Circum. | Provider |
| :--- | :--- | :--- | :--- | :--- | :--- |



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EFTA00073840

Inmate Name: EPSTEIN, JEFFREY EDWARD

Date of Birth: 01/20/1953

Encounter Date: 07/30/2019 11:12

<table border="1"><tr><td>Reg #:</td><td>76318-054</td></tr><tr><td>Facility:</td><td>NYM</td></tr><tr><td>Unit:</td><td>Z01</td></tr></table>

<table><thead><tr><th>Date</th><th>Time</th><th>Lbs</th><th>Kg</th><th>Waist Circum.</th><th>Provider</th></tr></thead><tbody><tr><td>07/30/2019</td><td>09:30 NYM</td><td>194.2</td><td>88.1</td><td></td><td></td></tr><tr><td colspan="6">exam:</td></tr><tr><td colspan="6">General</td></tr><tr><td colspan="6">Affect</td></tr><tr><td></td><td>Yes: Cooperative</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="6">Appearance</td></tr><tr><td></td><td>Yes: Appears Well, Alert and Oriented x 3</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkeen, Acutely Ill</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="6">Nutrition</td></tr><tr><td></td><td>No: Appears Obese</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="6">Pulmonary</td></tr><tr><td></td><td>Auscultation</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>Yes: Clear to Auscultation</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="6">Cardiovascular</td></tr><tr><td></td><td>Auscultation</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>No: M G</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="6">Musculoskeletal</td></tr><tr><td></td><td>Tibia / Fibula</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>No: Edema</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="6">Neurologic</td></tr><tr><td></td><td>Cranial Nerves (CN)</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>Yes: Within Normal Limits</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="6">Motor System-General</td></tr><tr><td></td><td>Yes: Normal Exam</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="6">Motor System-Strength</td></tr><tr><td></td><td>Yes: Normal Muscular Strength</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="6">SSESSMENT:</td></tr><tr><td colspan="6">Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current</td></tr><tr><td colspan="6">Constipation, unspecified, K5900 - Current</td></tr><tr><td colspan="6">Essential (primary) hypertension, I10 - Current - BY HX.</td></tr><tr><td colspan="6">Hyperlipidemia, unspecified, E785 - Current</td></tr><tr><td colspan="6">Low back pain, M545 - Current</td></tr><tr><td colspan="6">Neuralgia and neuritis, unspecified, M792 - Current</td></tr><tr><td colspan="6">Prediabetes, R7303 - Current</td></tr><tr><td colspan="6">Sleep apnea, G4730 - Current</td></tr><tr><td colspan="6">LAN:</td></tr><tr><td colspan="6">New Medication Orders:</td></tr><tr><td>x#</td><td>Medication</td><td>Order Date</td><td colspan="3">Prescriber Order</td></tr></tbody></table>

## Exam:

## PLAN:

Generated 07/30/2019 14:05 by

Bureau of Prisons - NYM

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EFTA00073841

| Inmate Name: | EPSTEIN, JEFFREY EDWARD |
| :--- | :--- |
| Date of Birth: | 01/20/1953 |
| Encounter Date: | 07/30/2019 11:12 |

| Sex: | M | Race: WHITE |
| :--- | :--- | :--- |
| Provider: | | |

Reg #: 76318-054
Facility: NYM
Unit: Z01

## New Medication Orders:

## Prescriber Order

<table border="1"><tr><td colspan="4">Renew Medication Orders:</td></tr><tr><td>Rx#</td><td>Medication</td><td>Order Date</td><td>Prescriber Order</td></tr><tr><td>121836-NYM</td><td>methylPREDNISolone 4 MG Tab(21 count Pack)</td><td>07/30/2019 11:12</td><td>Take the tablet by mouth as directed x 6 day(s)</td></tr><tr><td></td><td colspan="3">Indication: Neuralgia and neuritis, unspecified</td></tr></table>

## New Laboratory Requests:

<table><thead><tr><th>Details</th><th>Frequency</th><th>Due Date</th><th>Priority</th></tr></thead><tbody><tr><td>Lab Tests - Short List-General-CBC w/diff</td><td>One Time</td><td>08/01/2019 00:00</td><td>Routine</td></tr><tr><td>Lab Tests-P-PSA, Total</td><td></td><td></td><td></td></tr><tr><td>Lab Tests-U-Uric Acid</td><td></td><td></td><td></td></tr><tr><td>Lab Tests - Short List-General-Comprehensive Metabolic Profile (CMP)</td><td></td><td></td><td></td></tr><tr><td>Lab Tests-U-Urinalysis w/Reflex to Microscopic</td><td colspan="3">Page 011 of 148</td></tr><tr><td colspan="4">New Radiology Request Orders:</td></tr><tr><th>Details</th><th>Frequency</th><th>End Date</th><th>Due Date</th><th>Priority</th></tr><tr><td>General Radiology-Spine / Cervical-General</td><td>One Time(b)(6); (b)(7)(A); (b)(7)(C)</td><td>08/29/2019</td><td></td><td>Routine</td></tr></tbody></table>

Specific reason(s) for request (Complaints and findings):

66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUIMENESS RO 2-3 MINUTES 3 DAYS AGO.

PLEASE PERFORM C SPINE SERIES

**Disposition:**

Follow-up at Sick Call as Needed

## Patient Education Topics:

<table><thead><tr><th>Date Initiated</th><th>Format</th></tr></thead><tbody><tr><td>07/30/2019</td><td>Counseling</td></tr></tbody></table>

Handout/Topic

Access to Care



07/30/2019 Counseling



Plan of Care



<table><tr><td>Copay Required: No</td><td>Cosign Required: No</td></tr><tr><td>Telephone/Verbal Order: No</td><td></td></tr><tr><td>Completed by</td><td>on 07/30/2019 14:05</td></tr></table>

Generated 07/30/2019 14:05 by

Bureau of Prisons - NYM

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