EFTA00059517

| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M | Race: WHITE | Reg #: 76318-054 |
| :--- | :--- | :--- | :--- |
| Date of Birth: 01/20/1953 | | | Facility: NYM |
| Encounter Date: 07/14/2019 17:36 | Provider: | MD | Unit: Z05 |

## Exam:

## Eyes

General

Yes: PERRLA, Extraocular Movements Intact

## Pulmonary

# Cardiovascular

## Auscultation

Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2

No: M/R/G

<table><tr><td>Auscultation</td></tr><tr><td>Yes: Normo-Active Bowel Sounds</td></tr><tr><td>Palpation</td></tr><tr><td>Yes: Within Normal Limits</td></tr><tr><td>Musculoskeletal</td></tr><tr><td>Tibia / Fibula</td></tr><tr><td>No: Edema</td></tr><tr><td>Back</td></tr><tr><td>Yes: Tenderness</td></tr><tr><td>Neurologic</td></tr><tr><td>Cranial Nerves (CN)</td></tr><tr><td>Yes: Within Normal Limits</td></tr><tr><td>Motor System-General</td></tr><tr><td>Yes: Normal Exam</td></tr></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>

## PLAN:

<table><thead><tr><th colspan="2">New Medication Orders:</th></tr></thead><tbody><tr><td>Rx#</td><td>Medication</td></tr><tr><td></td><td>Omega 3 (Vascepa) 1 GM Capsule</td></tr></tbody></table>

<table><thead><tr><th>Order Date</th></tr></thead><tbody><tr><td>07/14/2019 17:36</td></tr></tbody></table>

## Indication: Hyperlipidemia, unspecified

New Laboratory Requests:

Details

Lab Tests-H-Hemoglobin A1C

Lab Tests-L-Lipid Profile

Additional Information:

Generated 07/14/2019 18:11 by

<table><thead><tr><th>Prescriber Order</th></tr></thead><tbody><tr><td>TAKE 2 CAPS Orally - Two Times a Day x 180 day(s) – TAKE WITH FOOD.</td></tr></tbody></table>

Frequency

One Time

Bureau of Prisons - NYM

<table><thead><tr><th>Due Date</th></tr></thead><tbody><tr><td>10/10/2019 00:00</td></tr></tbody></table>

**Priority**

Routine

Page 2 of 3

EFTA00059518

| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M Race: WHITE | Reg #: 76318-054 |
| :--- | :--- | :--- |
| Date of Birth: 01/20/1953 | Provider: MD | Facility: NYM |
| Encounter Date: 07/14/2019 17:36 | | Unit: Z05 |

**FASTING.**
Lab Tests-H-Hep B surface Ab
Lab Tests-H-Hep B surface Ag
Lab Tests-H-Hep C Ab
Lab Tests-H-Hepatic Profile

**Schedule:**

**Activity**
Clinical Encounter
66 YR OLD MALE FOR ROUTINE SCREENING.
Chronic Care Visit
6 MONTH F/U.
Chronic Care Visit

**Date Scheduled**
07/24/2019 00:00
01/07/2020 00:00
07/01/2020 00:00

**Scheduled Provider**
Optometrist
Mid-Level Provider
Physician 01

**Other:**
PENDING EKG AND FOBT. CXR WAS REFUSED.

**Patient Education Topics:**

| Date Initiated | Format | Handout/Topic | Provider | Outcome |
| :--- | :--- | :--- | :--- | :--- |
| 07/14/2019 | Counseling | Diagnosis | Beaudouin, Robert | Verbalizes Understanding |

**Copay Required:** No
**Telephone/Verbal Order:** No
Completed by MD on 07/14/2019 18:11

Generated 07/14/2019 18:11 by

MD

Bureau of Prisons - NYM