Full Text
Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/30/2019 11:12
Sex: M
Race: WHITE
Reg #: 76318-054
Provider:
Facility: NYM
Unit: Z01
Date
Time
Lbs
Kg
Waist Circum.
Provider
07/30/2019
09:30 NYM
194.2
88.1
(b)(6) (b)(7)(C)
MD
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: M/R/G
Musculoskeletal
Tibia / Fibula
No: Edema
Neurologic
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
Prescriber Order
Generated 07/30/2019 14:05 by (b)(6) (b)(7)(C)
MD
Bureau of Prisons - NYM
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