EFTA00138993

# 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 |

| Sex: | M | Race: WHITE |
| :--- | :--- | :--- |
| Provider: | MD | Unit: Z01 |

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

## SUBJECTIVE:

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 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.

Pain: Not Applicable

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

## OBJECTIVE:

## Exam:

## General

Affect

Yes: Cooperative

<table border="1"><tr><td>Appearance</td></tr><tr><td>Yes: Appears Well, Alert and Oriented x 3</td></tr><tr><td>No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely Ill</td></tr></table>

# Nutrition

No: Appears Obese

# Pulmonary

## Auscultation

Yes: Clear to Auscultation

## Cardiovascular

<table border="1"><tr><td>Auscultation</td></tr><tr><td>Yes: Regular Rate and Rhythm(RRR), Normal S1 and S2 No:M/R/G</td></tr></table>

# Musculoskeletal

## Tibia / Fibula

No: Edema

# Neurologic

Generated 07/30/2019 16:12 by

Bureau of Prisons - NYM

MD

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EFTA00138994

| Inmate Name: | EPSTEIN, JEFFREY EDWARD |

| :--- | :--- |

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

| Encounter Date: | 07/30/2019 15:58 |

<table border="1"><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:

<table border="1"><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 border="1"><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-BYHX.</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><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>

Indication: Prediabetes

<table border="1"><tr><td colspan="2">Discontinued Medication Orders:</td></tr><tr><td>Rx#</td><td>Medication</td></tr><tr><td>122148-NYM</td><td>Insulin Reg(10 ML) 100 UNITS/ML Inj</td></tr></table>

<table border="1"><tr><td>Prescriber Order</td></tr><tr><td>SLIDING SCALE</td></tr><tr><td>Subcutaneously each morning x</td></tr><tr><td>7 day(s) Pill Line Only</td></tr></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>MD on 07/30/2019 16:12</td></tr></table>

<table border="1"><tr><td>Inject regular insulin</td></tr><tr><td>subcutaneously per sliding scale:</td></tr><tr><td>twice daily ***pill line*** for 7 days</td></tr></table>

Prescriber Order

Generated 07/30/2019 16:12 by

MD



SDNY_00017358
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Bureau of Prisons - NYM