EFTA00132704

# Bureau of Prisons Health Services Clinical Encounter

| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M | Race: WHITE | Reg #: 76318-054 |
| :--- | :--- | :--- | :--- |
| Date of Birth: 01/20/1953 | | | Facility: NYM |
| Encounter Date: 07/30/2019 11:12 | Provider: | MD | Unit: Z01 |

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

## SUBJECTIVE:

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</td></tr></table>

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

## OBJECTIVE:

## Pulse:

## Respirations:

<table><thead><tr><th>Date</th><th>Time</th><th>Rate Per Minute</th><th>Provider</th></tr></thead><tbody><tr><td>07/30/2019</td><td>09:30 NYM</td><td>12</td><td>MD</td></tr></tbody></table>

## Blood Pressure:



GaO2:


## Weight:

<table><thead><tr><th>Date</th><th>Time</th><th>Lbs</th><th>Kg</th><th>Waist Circum.</th><th>Provider</th></tr></thead></table>

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EFTA00132705

| Inmate Name: | EPSTEIN, JEFFREY EDWARD |

| :--- | :--- |

| Date of Birth: | 01/20/1953 |

| Encounter Date: | 07/30/2019 11:12 |

| Sex: | M | Race: WHITE |

| :--- | :--- | :--- |

| Provider: | | MD |

<table><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>

## Exam:

## General

## Affect

<table><thead><tr><th>Category</th><th>Description</th></tr></thead><tbody><tr><td>Appearance</td><td>Yes: Appears Well, Alert and Oriented<br>No: Appears Distressed, Dyspneic<br>Disheveled, Unkempt, Acutely Ill</td></tr><tr><td>Nutrition</td><td>No: Appears Obese</td></tr><tr><td>Pulmonary</td><td>Auscultation<br>Yes: Clear to Auscultation</td></tr><tr><td>Cardiovascular</td><td>Auscultation<br>Yes: Regular Rate and Rhythm (RRR), Normal<br>No: M/R/G</td></tr><tr><td>Musculoskeletal</td><td>Tibia / Fibula<br>No: Edema</td></tr><tr><td>Neurologic</td><td>Cranial Nerves (CN)<br>Yes: Within Normal Limits</td></tr><tr><td>Motor System-General</td><td>Yes: Normal Exam</td></tr><tr><td>Motor System-Strength</td><td>Yes: Normal Muscular Strength</td></tr></tbody></table>

## ASSESSMENT:

<table><tr><td>Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current</td></tr><tr><td>Constipation, unspecified, K5900 - Current</td></tr><tr><td>Essential (primary) hypertension, I10 - Current - BY HX.</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>Prediabetes, R7303 - Current</td></tr><tr><td>Sleep apnea, G4730 - Current</td></tr></table>

## PLAN:

<table><tr><td colspan="2">New Medication Orders:</td></tr><tr><td>Rx#</td><td>Medication</td></tr></table>



Order Date



Prescriber Order

Generated 07/30/2019 14:05 by

MD

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Bureau of Prisons - NYM

EFTA00132706

| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M | Race: WHITE | Reg #: 76318-054 |
| :--- | :--- | :--- | :--- |
| Date of Birth: 01/20/1953 | | | Facility: NYM |
| Encounter Date: 07/30/2019 11:12 | Provider: | MD | Unit: Z01 |

<table><thead><tr><th>Rx#</th><th>Medication</th><th>Order Date</th><th>Prescriber Order</th></tr></thead><tbody><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 colspan="4">Indication: Neuralgia and neuritis, unspecified</td></tr></tbody></table>

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

PLEASE PERFORM C SPINE SERIES

## Disposition:

Follow-up at Sick Call as Needed

## Patient Education Topics:

<table border="1"><tr><td>Date Initiated</td><td>Format</td><td>Handout/Topic</td></tr><tr><td>07/30/2019</td><td>Counseling</td><td>Access to Care</td></tr></table>

| 07/30/2019 | Counseling |

| :--- | :--- |



Telephone/Verbal Order: No

Completed by . MD on 07/30/2019 14:05

Generated 07/30/2019 14:05 by

Page 3 of 3

MD

Bureau of Prisons - NYM