EFTA00073865

Inmate Name: EPSTEIN, JEFFREY EDWARD

Date of Birth: 01/20/1953

Encounter Date: 07/12/2019 13:10

Sex:
Provider:

M Race: WHITE

<table><tr><td>Reg #:</td><td>76318-054</td></tr><tr><td>Facility:</td><td>NYM</td></tr><tr><td>Unit:</td><td>Z05</td></tr></table>

## Exam:

# Eyes

## General

Yes: [ ] , Extraocular Movements Intact

## Pulmonary

<table><tr><td>Auscultation</td></tr><tr><td>Yes: Clear to Auscultation</td></tr></table>

Cardiovascular

Auscultation

Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2

No: M/G



Abdomen

Auscultation

Yes: Normo-Active Bowel S



<table><tr><td>Palpation</td></tr><tr><td>Yes: Within Normal Limits</td></tr></table>

<table><tr><td>Musculoskeletal</td></tr><tr><td>Tibia / Fibula</td></tr><tr><td>No: Edema</td></tr><tr><td>Back</td></tr><tr><td>Yes: Tenderness</td></tr></table>

<table border="1"><tr><td colspan="2">Neurologic</td></tr><tr><td>Cranial Nerves(CN)</td><td>(b)(6);(b)(7)(A);(b)(7)(C)</td></tr><tr><td>Yes:Within Normal Limits</td><td>of the Freedom of Information and Privacy Act</td></tr><tr><td>Motor System-General</td><td></td></tr><tr><td>Yes:Normal Exam</td><td></td></tr></table>

## ASSESSMENT:

<table border="1"><tr><td>Constipation, unspecified, K5900 - Current</td></tr><tr><td>Hyperlipidemia, unspecified, E785 - Current</td></tr><tr><td>Low back pain, M545 - Current</td></tr><tr><td>Neuralgia and neuritis, unspecified, M792 - Current</td></tr><tr><td>Sleep apnea, G4730 - Current</td></tr></table>

## PLAN:

<table><thead><tr><th colspan="2">New Medication Orders:</th></tr></thead><tbody><tr><td>Rx#</td><td>Medication</td></tr><tr><td></td><td>Magnesium Hydroxide Susp</td></tr></tbody></table>

<table><thead><tr><th>Order Date</th></tr></thead><tbody><tr><td>07/12/2019 13:10</td></tr></tbody></table>

<table><thead><tr><th>Prescriber Order</th></tr></thead><tbody><tr><td>30 CC Orally - Two Times a Day PRN x 2 day(s)</td></tr></tbody></table>

<table border="1"><tr><td>Indication:</td><td>Constipation, unspecified</td></tr><tr><td>MethylPREDNISolone Tab 4 MG(Dose Pack 21 tab)</td><td>07/12/2019 13:10</td></tr><tr><td>Indication:</td><td>Neuralgia and neuritis, unspecified</td></tr></table>

AS DIRECTED Orally - daily x 6 day(s)

## Disposition:

Generated 07/12/2019 14:20 by

Bureau of Prisons - NYM

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