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:¶
| Subjective: | 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 |
| 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, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely Ill |
Bureau of Prisons - NYM¶
Page 1 of 3¶
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¶
| General | |
|---|---|
| Yes: PERRLA, Extraocular Movements Intact | |
| Pulmonary | |
| Auscultation | Yes: Clear to Auscultation |
| Cardiovascular | |
| Auscultation | Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2 |
| No: M/R/G | |
| Abdomen | |
| Auscultation | Yes: Normo-Active Bowel Sounds |
| 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 |
| New Medication Orders: | |
| Rx# | Medication |
| Magnesium Hydroxide Susp | |
PLAN:¶
| Order Date |
| 07/12/2019 13:10 |
| Indication: Constipation, unspecified |
| MethylPREDNISolone Tab 4 MG (Dose 07/12/2019 13:10 Pack 21 tab) |
| Indication: Neuralgia and neuritis, unspecified |
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¶
Page 2 of 3¶
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:¶
| Date Initiated | Format |
|---|---|
| 07/12/2019 | Counseling |
Copay Required: No¶
| Handout/Topic |
| Diagnosis |
Provider¶
Completed by¶
Telephone/Verbal Order:¶
Cosign Required: No¶
MD on 07/12/2019 14:20¶
| Outcome |
|---|
| Verbalizes |
| Understanding |
Generated 07/12/2019 14:20 by¶
MD¶
Page 3 of 3¶
Bureau of Prisons - NYM¶