EFTA00073863

| Inmate Name: | EPSTEIN, JEFFREY EDWARD |

| :--- | :--- |

| Date of Birth: | 01/20/1953 |

| Encounter Date: | 07/14/2019 17:36 |

Sex:

Provider:

<table border="1"><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>

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

One Time

<table border="1"><tr><td>Activity</td><td>Date Scheduled</td><td>Scheduled Provider</td></tr><tr><td>Clinical Encounter66 YR OLD MALE FOR ROUTINE SCREENING.</td><td>07/24/2019 00:00</td><td>Optometrist</td></tr><tr><td>Chronic Care Visit6 MONTH F/U.</td><td>01/07/2020 00:00</td><td>Mid-Level Provider</td></tr><tr><td>Chronic Care Visit</td><td>07/01/2020 00:00</td><td>Physician 01</td></tr></table>

Other:

PENDING EKG AND FOBT. CXR WAS REFUSED.

<table border="1"><tr><td colspan="2">Patient Education Topics:</td></tr><tr><td>Date Initiated</td><td>Format</td></tr><tr><td>07/14/2019</td><td>Counseling</td></tr></table>

Handout/Topic

Diagnosis

Provider

<table><tr><td>Copay Required: No</td></tr><tr><td>Telephone/Verbal Order: No</td></tr></table>

Cosign Required: No Page 033 of 148

Completed by

Withheld pursuant to exemption on 07/14/2019 18:11

(b)(6) ; (b)(7)(A) ; (b)(7)(C)

<table><thead><tr><th>Outcome</th></tr></thead><tbody><tr><td>Verbalizes</td></tr><tr><td>Understanding</td></tr></tbody></table>

of the Freedom of Information and Privacy Act

Generated 07/14/2019 18:11 by

Bureau of Prisons - NYM

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EFTA00073864

# 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: 07/12/2019 13:10

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

Date: 07/12/2019 13:25 Page 034 of 148

<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 ROSERAGK of the Freedom of Information and Privacy Act

Trauma Date/Year:

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:

**Seen for clinic(s):** Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology

**Added to clinic(s):** Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology

## OBJECTIVE:

## Exam:

# 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

Bureau of Prisons - NYM

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