EFTA00033827
## Bureau of Prisons Health Services Clinical Encounter
| Inmate Name: | EPSTEIN. JEFFREY EDWARD | | | | Reg tit: | 76318.054 |
|----------------|----------------------------------|-----------|---|-------------|---------------|-----------|
| Date of Birth: | 01/20/1953 | Sex: | M | Race: WHITE | Facility: NYM | |
| | Encounter Date: 07/12/2019 13:10 | Provider: | | | Unit: | Z05 |
Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE:
| Chief Complaint: ENDO/LIPID
Subjective:
66 YR OL
HITE MALE WITH HX OF
HYPERT;
STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE
800 ,
EIR GI SIDE EFFECTS.
MEDS
•
UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP
HX OF O
4
MACHINE. -I, 1-Nr*
HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED.
a
STATES THE
Y HAS
SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE
L4 - L5 SEVERE
LOWER EXTREMI
SURGICAL FIX: NONE
MENTAL HEALTH FIX:
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: | COMPLAINT 1 | Provider: |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------|-------------------------------------------------------------|
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| | | CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS |
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| 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, Pale. Pallor. Cyanotic. Diaphoretic, Disheveled, Unkempt, Acutely III
#### Nutrition
No: Appears Obese Generated 07112,2019 14 20 by Bureau of Prisons - NYM Page 1 of 3
# CONFIDENTIAL SDNY 00009422
M Race: WHITE
#### Exam:
#### Eyes
#### General
Yes: PERRLA, Exlraocular Movements Intact
#### Pulmonary
#### Auscultation
Yes: Clear to Auscultation
#### Cardiovascular
#### Auscultation
Yes: Regular Rat Rhythm (RRR), Normal S1 and S2
#### No: WR/G
#### Abdomen
#### Auscultation
Yes: Normo-Active B
#### Palpation
Yes: Within Normal Limits
#### Musculoskeletal
Tibia / Fibula
No: Edema
Back
Yes: Tenderness
#### Neurologic
Cranial Nerves (CN)
Yes: Within 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 | | | | | | |
|-----|--------------------------|--|--|--|--|--|--|
| | Magnesium Hydroxide Susp | | | | | | |
Indication: Constipation, unspecified MethyIPREDNISolone Tab 4 MG ( Dose Pack 21 tab) Indication: Neuralgia and neuritis, unspecified
07/12/2019 13:10
Order Date 07/12/2019 13:10
#### aescriber Order
30 CC Orally - Two Times a Day PRN x 2 day(s)
AS DIRECTED Orally - daily x 6 day(s)
Disposition:
Corer:nod 01:17,2019 1420 by
Bureau of Prisons - NYM
Page 2 of 3
# CONFIDENTIAL SDNY 00009423
Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/12/2019 13:10
Reg #: 76318.054 Sex: M Race: WHITE Facility: NYM Provider: El Unit: Z05
Follow-up at Sick Call as Needed
#### Other:
WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP.
| Patient Education Topics: | | | | |
|------------------------------|----------------------|----------------------------|----------|-----------------------|
| Date Initiated
07/12/2019 | Format
Counseling | Handout/Tonic
Diagnosis | Provider | Outcome
Verbalizes |
| | | | | Understanding |
| Copay Required: No | | Cosign Required: No | | |
| TelephoneNerbal Order: | | | | |
| Cornpteled CI | | n 07/12/2019 14:20 | | |
| | | | | |
CONFIDENTIAL SDNY_00 009424