EFTA00073861

Bureau of Prisons Health Services Clinical Encounter

Inmate Name: EPSTEIN, JEFFREY EDWARD

Date of Birth: 01/20/1953



Reg #: 76318-054



Race: WHITE

Sex:

Provider:

Encounter Date: 07/14/2019 17:36

Facility: NYM

Unit: Z05

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

## SUBJECTIVE:



COMPLAINT 1 Provider:



Chief Complaint: ENDO/LIPID

<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>

| Pain: | Yes |

| :--- | :--- |

## Pain Assessment

<table><thead><tr><th>Date:</th><th>07/12/2019 13:25</th><th>Page 031 of 148</th></tr></thead></table>

<table><thead><tr><th>Location:</th><th>Back-Middle</th><th>Withheld pursuant to exemption</th></tr></thead></table>

Quality of Pain: Shooting

Pain Scale: 5

Intervention: MEDRO of the Freedom of Information and Privacy Act

Trauma Date/Year:

Injury:

Mechanism:

<table><thead><tr><th>Onset:</th><th>5+ Years</th></tr></thead></table>



Duration: 5+ Years



Exacerbating Factors: NO EXERCISE

Relieving Factors: MEDROL DOSE PACK

Reason Not Done:

Comments:

<table><tr><td>Seen for clinic(s):</td><td>Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid</td></tr><tr><td>Added to clinic(s):</td><td>Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid</td></tr></table>

## 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 07/14/2019 18:11 by

Bureau of Prisons - NYM

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EFTA00073862

Inmate Name: EPSTEIN, JEFFREY EDWARD

Date of Birth: 01/20/1953

Encounter Date: 07/14/2019 17:36

Sex:
Provider:

M Race: WHITE

<table><tr><td>Reg #:</td><td>76318-054</td></tr><tr><td>Facility:</td><td>NYM</td></tr><tr><td>Unit:</td><td>Z05</td></tr></table>

## Exam:

# Eyes

## General

Yes: [ ] , Extraocular Movements Intact

<table><tr><td>Pulmonary Auscultation</td></tr><tr><td>Yes: Clear to Auscultation</td></tr></table>

# Cardiovascular

## Auscultation

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

No: M/G

<table><tr><td>Abdomen</td></tr><tr><td>Auscultation</td></tr><tr><td>Yes: Normo-Active Bowel Sounds</td></tr></table>

# Palpation

Yes: Within Normal Limits

<table><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></table>

<table border="1"><tr><td colspan="2">Neurologic</td></tr><tr><td>Cranial Nerves(CN)</td><td>(b)(6);(b)(7)(A);(b)(7)(C)</td></tr><tr><td>Yes:Within Normal Limits</td><td>of the Freedom of Information and Privacy Act</td></tr><tr><td>Motor System-General</td><td></td></tr><tr><td>Yes:Normal Exam</td><td></td></tr></table>

## ASSESSMENT:

<table border="1"><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>

New Laboratory Requests:

Details

Lab Tests-H-Hemoglobin A1C

Lab Tests-L-Lipid Profile

Additional Information:

Generated 07/14/2019 18:11 by

Indication: Hyperlipidemia, unspecified

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

<table><tr><td>Frequency</td></tr><tr><td>One Time</td></tr></table>

Generated 07/14/2019 18:11 by

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

Bureau of Prisons - NYM



Priority

Routine



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