EFTA00073865¶
Inmate Name: EPSTEIN, JEFFREY EDWARD¶
Date of Birth: 01/20/1953¶
Encounter Date: 07/12/2019 13:10¶
Sex: Provider:¶
M Race: WHITE¶
| Reg #: | 76318-054 |
| Facility: | NYM |
| Unit: | Z05 |
Exam:¶
Eyes¶
General¶
Yes: [ ] , Extraocular Movements Intact¶
Pulmonary¶
| Auscultation |
| Yes: Clear to Auscultation |
Cardiovascular¶
Auscultation¶
Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2¶
No: M/G¶
Abdomen¶
Auscultation¶
Yes: Normo-Active Bowel S¶
| Palpation |
| Yes: Within Normal Limits |
| Musculoskeletal |
| Tibia / Fibula |
| No: Edema |
| Back |
| Yes: Tenderness |
| Neurologic | |
| Cranial Nerves(CN) | (b)(6);(b)(7)(A);(b)(7)(C) |
| Yes:Within Normal Limits | of the Freedom of Information and Privacy Act |
| Motor System-General | |
| Yes:Normal Exam | |
ASSESSMENT:¶
| Constipation, unspecified, K5900 - Current |
| Hyperlipidemia, unspecified, E785 - Current |
| Low back pain, M545 - Current |
| Neuralgia and neuritis, unspecified, M792 - Current |
| Sleep apnea, G4730 - Current |
PLAN:¶
| New Medication Orders: | |
|---|---|
| Rx# | Medication |
| Magnesium Hydroxide Susp | |
| Order Date |
|---|
| 07/12/2019 13:10 |
| Prescriber Order |
|---|
| 30 CC Orally - Two Times a Day PRN x 2 day(s) |
| Indication: | Constipation, unspecified |
| MethylPREDNISolone Tab 4 MG(Dose Pack 21 tab) | 07/12/2019 13:10 |
| Indication: | Neuralgia and neuritis, unspecified |
AS DIRECTED Orally - daily x 6 day(s)¶
Disposition:¶
Generated 07/12/2019 14:20 by¶
Bureau of Prisons - NYM¶
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