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: |
|---|---|---|
| CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS | ||
| 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¶