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¶
| 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: | Yes |¶
| :--- | :--- |¶
Pain Assessment¶
| Date: | 07/12/2019 13:25 | Page 031 of 148 |
|---|
| Location: | Back-Middle | Withheld pursuant to exemption |
|---|
Quality of Pain: Shooting¶
Pain Scale: 5¶
Intervention: MEDRO of the Freedom of Information and Privacy Act¶
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): | Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid |
| Added to clinic(s): | Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid |
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¶
Page 1 of 3¶
EFTA00073862¶
Inmate Name: EPSTEIN, JEFFREY EDWARD¶
Date of Birth: 01/20/1953¶
Encounter Date: 07/14/2019 17:36¶
Sex: Provider:¶
M Race: WHITE¶
| Reg #: | 76318-054 |
| Facility: | NYM |
| Unit: | Z05 |
Exam:¶
Eyes¶
General¶
Yes: [ ] , Extraocular Movements Intact¶
| Pulmonary Auscultation |
| Yes: Clear to Auscultation |
Cardiovascular¶
Auscultation¶
Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2¶
No: M/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) | (b)(6);(b)(7)(A);(b)(7)(C) |
| Yes:Within Normal Limits | of the Freedom of Information and Privacy Act |
| 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 |
| Omega 3 (Vascepa) 1 GM Capsule | |
| Order Date |
|---|
| 07/14/2019 17:36 |
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¶
| Prescriber Order |
|---|
| TAKE 2 CAPS Orally - Two Times a Day x 180 day(s) -- |
| TAKE WITH FOOD. |
| Frequency |
| One Time |
Generated 07/14/2019 18:11 by¶
| Due Date |
|---|
| 10/10/2019 00:00 |
Bureau of Prisons - NYM¶
Priority¶
Routine¶
Page 2 of 3¶