EFTA00134773

Bureau of Prisons
Health Services
Clinical Encounter

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encourier Date: 07/30/2019 15:58
Provider: [Name]

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

SUBJECTIVE:

COMPLAINT 1 Provider:
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 NUMBINESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. HE DENIES RIGHT SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OR SWALLOWING.
HE REPORTS NOCTURNA 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.

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, Dysnecic, Appears In Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Dishevelled, 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: M/R/G
Musculoskeletal
Tibia / Fibula
No: Edema
Neurologic

Generated 07/30/2019 16:12 by Beaudouin, MD
Bureau of Prisons - NYM

EFTA00134774

<table><tr><td>Cranial Nerves (CN)</td></tr><tr><td>Yes: Within Normal Limits</td></tr><tr><td>Motor System-General</td></tr><tr><td>Yes: Normal Exam</td></tr><tr><td>Motor System-Strength</td></tr><tr><td>Yes: Normal Muscular Strength</td></tr></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>

<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>INsulin REG - Human</td></tr></tbody></table>

<table><thead><tr><th>Order Date</th></tr></thead><tbody><tr><td>07/30/2019 15:58</td></tr></tbody></table>

<table><thead><tr><th>Rx#</th><th>Medication</th></tr></thead><tbody><tr><td>122148-NYM</td><td>Insulin Reg (10 ML) 100 UNITS/ML Inj</td></tr></tbody></table>

<table><thead><tr><th>Order Date</th></tr></thead><tbody><tr><td>07/30/2019 15:58</td></tr></tbody></table>

<table border="1"><tr><td>Discontinue Type:</td><td>When Pharmacy Processes</td></tr><tr><td>Discontinue Reason:</td><td>new order written</td></tr><tr><td>Indication:</td><td></td></tr></table>

<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 16:12</td></tr></table>

<table><thead><tr><th>Prescriber Order</th></tr></thead><tbody><tr><td>SLIDING SCALE</td></tr><tr><td>Subcutaneously each morning x</td></tr><tr><td>7 day(s) Pill Line Only</td></tr></tbody></table>

# Prescriber Order

Inject regular insulin

subcutaneously per sliding scale:

twice daily ***pill line*** for 7 days

Bureau of Prisons - NYM

Generated 07/30/2019 16:12 by

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