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 OrderӦ
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¶