EFTA00059459

# Bureau of Prisons Health Services Clinical Encounter

| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M Race: WHITE | Reg #: 76318-054 |
| :--- | :--- | :--- |
| Date of Birth: 01/20/1953 | Provider: MD | Facility: NYM |
| Encounter Date: 07/12/2019 13:10 | | Unit: Z05 |

Chronic Care - 14 Day Physician Eval encounter performed at Health Services.

## SUBJECTIVE:

<table><tr><td>Subjective:</td><td>66 YR OLD WHITE MALE WITH HX OF HYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800, NOW 431. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS DUE TO THEIR GI SIDE EFFECTS.

HX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE FBI LOKELY HAS

L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES.

SURGICAL HX: NONE

MENTAL HEALTH HX: NONE</td></tr></table>

<table><tr><td colspan="2">Pain Assessment</td></tr><tr><td>Date:</td><td>07/12/2019 13:25</td></tr><tr><td>Location:</td><td>Back-Middle</td></tr><tr><td>Quality of Pain:</td><td>Shooting</td></tr><tr><td>Pain Scale:</td><td>5</td></tr><tr><td>Intervention:</td><td>MEDROL DOSE PACK</td></tr><tr><td>Trauma Date/Year:</td><td></td></tr><tr><td>Injury:</td><td></td></tr><tr><td>Mechanism:</td><td></td></tr><tr><td>Onset:</td><td>5+ Years</td></tr><tr><td>Duration:</td><td>5+ Years</td></tr><tr><td>Exacerbating Factors:</td><td>NO EXERCISE</td></tr><tr><td>Relieving Factors:</td><td>MEDROL DOSE PACK</td></tr><tr><td>Reason Not Done:</td><td></td></tr><tr><td>Comments:</td><td></td></tr></table>

| Seen for clinic(s): | Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology |

| :--- | :--- |

| Added to clinic(s): | Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology |

## OBJECTIVE:

## Exam:

## General

<table border="1"><tr><td>Appearance</td><td></td></tr><tr><td>Yes: Appears Well, Alert and Oriented x 3</td><td></td></tr><tr><td>No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely Ill</td><td></td></tr></table>

Bureau of Prisons - NYM

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EFTA00059460

| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M Race: WHITE | Reg #: 76318-054 |
| :--- | :--- | :--- |
| Date of Birth: 01/20/1953 | Facility: NYM |
| Encounter Date: 07/12/2019 13:10 | Unit: Z05 |

## Exam:

## Eyes

<table><thead><tr><th></th><th>General</th></tr></thead><tbody><tr><td></td><td>Yes: PERRLA, Extraocular Movements Intact</td></tr><tr><td colspan="2">Pulmonary</td></tr><tr><td>Auscultation</td><td>Yes: Clear to Auscultation</td></tr><tr><td colspan="2">Cardiovascular</td></tr><tr><td>Auscultation</td><td>Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2</td></tr><tr><td></td><td>No: M/R/G</td></tr><tr><td colspan="2">Abdomen</td></tr><tr><td>Auscultation</td><td>Yes: Normo-Active Bowel Sounds</td></tr><tr><td colspan="2">Palpation</td></tr><tr><td></td><td>Yes: Within Normal Limits</td></tr><tr><td colspan="2">Musculoskeletal</td></tr><tr><td>Tibia / Fibula</td><td>No: Edema</td></tr><tr><td colspan="2">Back</td></tr><tr><td></td><td>Yes: Tenderness</td></tr><tr><td colspan="2">Neurologic</td></tr><tr><td>Cranial Nerves (CN)</td><td>Yes: Within Normal Limits</td></tr><tr><td colspan="2">Motor System-General</td></tr><tr><td></td><td>Yes: Normal Exam</td></tr></tbody></table>

## ASSESSMENT:

<table><tr><td>Constipation, unspecified, K5900 - Current</td></tr><tr><td>Hyperlipidemia, unspecified, E785 - Current</td></tr><tr><td>Low back pain, M545 - Current</td></tr><tr><td>Neuralgia and neuritis, unspecified, M792 - Current</td></tr><tr><td>Sleep apnea, G4730 - Current</td></tr></table>

<table><tr><td colspan="2">New Medication Orders:</td></tr><tr><td>Rx#</td><td>Medication</td></tr><tr><td></td><td>Magnesium Hydroxide Susp</td></tr></table>

## PLAN:

<table border="1"><tr><td>Order Date</td></tr><tr><td>07/12/2019 13:10</td></tr></table>

<table><tr><td>Indication: Constipation, unspecified</td></tr><tr><td>MethylPREDNISolone Tab 4 MG (Dose 07/12/2019 13:10 Pack 21 tab)</td></tr><tr><td>Indication: Neuralgia and neuritis, unspecified</td></tr></table>

## Prescriber Order

## Disposition:

30 CC Orally - Two Times a Day PRN x 2 day(s)



AS DIRECTED Orally - daily x 6 day(s)



Generated 07/12/2019 14:20 by

Bureau of Prisons - NYM

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MD

EFTA00059461

| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M Race: WHITE | Reg #: 76318-054 |
| :--- | :--- | :--- |
| Date of Birth: 01/20/1953 | Facility: NYM |
| Encounter Date: 07/12/2019 13:10 | Unit: Z05 |

Follow-up at Sick Call as Needed

Other:

WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP.

Patient Education Topics:

<table><thead><tr><th>Date Initiated</th><th>Format</th></tr></thead><tbody><tr><td>07/12/2019</td><td>Counseling</td></tr></tbody></table>

Copay Required: No

<table border="1"><tr><td>Handout/Topic</td></tr><tr><td>Diagnosis</td></tr></table>



Provider



Completed by

Telephone/Verbal Order:

Cosign Required: No

MD on 07/12/2019 14:20

<table><thead><tr><th>Outcome</th></tr></thead><tbody><tr><td>Verbalizes</td></tr><tr><td>Understanding</td></tr></tbody></table>

Generated 07/12/2019 14:20 by

MD

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Bureau of Prisons - NYM