EFTA00132699¶
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 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 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 SINCE WEAKNESS, DISLOPIA, 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 HAS BEB ENERE SINCE HE DIE NOT HAVE ACCESS THI CPAP MACHINE. I INFORM ME THAT WE RECEIVED His CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONGHT. 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: MR/G Musculoskeletal Tibia / Fibula No: Edema Neurologic¶
dated 07/30/2019 16:12 by MD Bureau of Prisons - NYM¶
EFTA00132700¶
Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/30/2019 15:58¶
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 - BY HX. Hyperlipidemia, 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 INeulin REG - Human 07/30/2019 15:58¶
Indication: Prediabetes¶
Discontinued Medication Orders: Rx# Medication Order Date 122148-NYM Insulin Reg (10 ML) 100 UNITS/ML Inj 07/30/2019 15:58¶
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¶