EFTA00059462¶
Bureau of Prisons Health Services Clinical Encounter¶
| Inmate Name: | EPSTEIN, JEFFREY EDWARD |
|---|---|
| Date of Birth: | 01/20/1953 |
| Encounter Date: | 07/12/2019 13:10 |
| Sex: | M | Race: WHITE |
|---|---|---|
| Provider: | MD | 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 LOCKELY HASL4-L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES.SURGICAL HX:NONEMENTAL HEALTH HX:NONE |
| 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, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely Ill |
Nutrition¶
No: Appears Obese¶
Generated 07/12/2019 14:20 by¶
Page 1 of 3¶
MD¶
Bureau of Prisons - NYM¶
EFTA00059463¶
| Inmate Name: | EPSTEIN, JEFFREY EDWARD |
|---|---|
| Date of Birth: | 01/20/1953 |
| Encounter Date: | 07/12/2019 13:10 |
| Sex: | M | Race: WHITE |
|---|---|---|
| Provider: | MD | 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 |
PLAN:¶
| New Medication Orders: | |
| Rx# | Medication |
| Magnesium Hydroxide Susp | |
| 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¶
| Prescriber Order |
|---|
| 30 CC Orally - Two Times a Day PRN x 2 day(s) |
Disposition:¶
Generated 07/12/2019 14:20 by¶
AS DIRECTED Orally - daily x 6 day(s)¶
Bureau of Prisons - NYM¶
MD¶
Page 2 of 3¶
EFTA00059464¶
| 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¶
Telephone/Verbal Order:¶
Completed by¶
Cosign Required: No¶
| MD on | 07/12/2019 | 14:20 |¶
| :--- | :--- | :--- |¶
Generated 07/12/2019 14:20 by¶
MD¶
Bureau of Prisons - NYM¶
Page 3 of 3¶