## Bureau of Prisons Health Services Clinical Encounter
| EPSTEIN, JEFFREY EDWARD
Inmate Name:
01/20/1953
Date of Birth:
Encounter Date: 07/12/2019 13:10 | Sex:
Provider: | | | Race: WHITE | Reg SI:
Facility: NYM
Unit: | 76318-054
Z05 | |
|-------------------------------------------------------------------------------------------------------------|-------------------|--|--|-------------|-----------------------------------|------------------|--|
|-------------------------------------------------------------------------------------------------------------|-------------------|--|--|-------------|-----------------------------------|------------------|--|
Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE:
| COMPLAINT 1 | | Provider: |
|-----------------------------|----------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Chief Complaint: ENDO/LIPID | | |
| Subjective: | 66 YR OL
HYPERT
800 ,
MEDS
HX OF O
MACHINE.
STATES THE
L4 - LS SEVERE
LOWER EXTREMI
SURGICAL HX: NONE | HITE MALE WITH FIX OF
CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS
STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE
EIR GI SIDE EFFECTS.
•
UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP
it
HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED.
:
Y HAS
SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE
S
MENTAL HEALTH HX: |
| Pain: | Yes | |
| Pain Assessment | | |
| Date: | | 07/12/2019 13:25 |
| Location: | | Back-Middle |
| Quality of Pain: | | Shooting |
| Pain Scale: | | 5 |
| Intervention: | | MEDROL DOSE PACK |
| Trauma Date/Year: | | |
| Injury: | | |
| Mechanism: | | |
| Onset: | | 5+ Years |
| Duration: | | 5+ Years |
| | | Exacerbating Factors: NO EXERCISE |
| Relieving Factors: | | MEDROL DOSE PACK |
| Reason Not Done: | | |
| Comments: | | |
| | | |
Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology
#### OBJECTIVE:
#### Exam:
General
#### Appearance
Yes: Appears Well, Alert and Oriented x 3
No: Appears Distressed. Dyspneic. Appears in Pain. Writhing in Pain, Pate. Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt. Acutely 111
#### Nutrition
No: Appears Obese Generated 07/7212019 14.20 by Bureau of Prisons • NYM Page I of 3
# CONFIDENTIAL SDNY_00009419
M Race: WHITE
#### Exam:
Eyes
#### General
Yes: PERRLA, Extraocular Movements Intact
#### Pulmonary
#### Auscultation
Yes: Clear to Auscultation
#### Cardiovascular
#### Auscultation
Yes: Regular Rat Rhythm (RRR), Normal S1 and S2
No: M/R/G
#### Abdomen
Auscultation
Yes: Normo-Active B
#### Palpation
Yes: Within Normal Limits
#### Musculoskeletal
Tibia / Fibula
No: Edema
#### Back
Yes: Tenderness
#### Neurologic
Cranial Nerves (CN)
ithi Yes: W n Normal Limits
Motor System-General
Yes: Normal Exam
#### ASSESSMENT:
Constipation, unspecified, K5900 - Current Hyperlipidemia, unspecified, E785 - Current Low back pain. M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Sleep apnea, G4730 - Current
#### PLAN:
#### New Medication Orders:
| Rx# | Medication | QrtesEpa | |
|-----|--------------------------|------------------|--|
| | Magnesium Hydroxide Susp | 07/12/2019 13:10 | |
Indication: Constipation, unspecified MethyiPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 Pack 21 tab) Indication: Neuralgia and neuritis. unspecified
4 7 4 0.1)0
#### Prescriber Order"
30 CC Orally - Two Times a Day PRN x 2 day(s)
>e,
AS DIRECTED Orally - daily x 6 day(s)
Disposition:
Generated 07/122019 14:20 by
Bureau of Prisons - NYM Page 2 of 3
# CONFIDENTIAL SDNY_00009420
Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/12/2019 13:10 Provider: I
Reg #: 76318-054 Facility: NYM Unit: Z05
Follow-up at Sick Call as Needed
#### Other:
WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP.
| Patient Education Topics: | | | | |
|---------------------------|------------|---------------------|----------|-----------------------------|
| Pate Initiates'. | Format | ~UTop!
Han | Provider | Outcome |
| 07/12/2019 | Counseling | Diagnosis | | Verbalizes
Understanding |
| Copay Required: No | | Cosign Required: No | | |
| TelephoneNerbal Order: | | | | |
| Completed by Beaudouin. | n | 07/12/2019 14:20 | | |
CONFIDENTIAL SDNY 00009421