EFTA00073863¶
| Inmate Name: | EPSTEIN, JEFFREY EDWARD |¶
| :--- | :--- |¶
| Date of Birth: | 01/20/1953 |¶
| Encounter Date: | 07/14/2019 17:36 |¶
Sex:¶
Provider:¶
| Reg #: | 76318-054 |
| Facility: | NYM |
| 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¶
One Time¶
| Activity | Date Scheduled | Scheduled Provider |
| Clinical Encounter66 YR OLD MALE FOR ROUTINE SCREENING. | 07/24/2019 00:00 | Optometrist |
| Chronic Care Visit6 MONTH F/U. | 01/07/2020 00:00 | Mid-Level Provider |
| Chronic Care Visit | 07/01/2020 00:00 | Physician 01 |
Other:¶
PENDING EKG AND FOBT. CXR WAS REFUSED.¶
| Patient Education Topics: | |
| Date Initiated | Format |
| 07/14/2019 | Counseling |
Handout/Topic¶
Diagnosis¶
Provider¶
| Copay Required: No |
| Telephone/Verbal Order: No |
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)¶
| Outcome |
|---|
| Verbalizes |
| Understanding |
of the Freedom of Information and Privacy Act¶
Generated 07/14/2019 18:11 by¶
Bureau of Prisons - NYM¶
Page 3 of 3¶
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¶
| 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 034 of 148¶
| Location: | Back-Middle | Withheld pursuant to exemption |
|---|
Quality of Pain: Shooting¶
Pain Scale: 5¶
Intervention: MEDRO ROSERAGK of the Freedom of Information and Privacy Act¶
Trauma Date/Year:¶
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:¶
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¶
Page 1 of 3¶