EFTA00073866

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/12/2019 13:10

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>

Follow-up at Sick Call as Needed

Other:

WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP.

# Patient Education Topics:

| Date Initiated | Format |

| :--- | :--- |

| 07/12/2019 | Counseling |

Handout/Topic

Diagnosis

Provider

<table><tr><td>Copay Required: No</td><td>Cosign Required: No</td></tr><tr><td>Telephone/Verbal Order: No</td><td></td></tr><tr><td colspan="2">Completed by Beaudouin, Robert MD on 07/12/2019 14:20</td></tr></table>

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



Page 036 of 148

Withheld pursuant to exemption

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

of the Freedom of Information and Privacy Act



Generated 07/12/2019 14:20 by

Page 3 of 3

Bureau of Prisons - NYM

EFTA00073867

# 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:

Facility: NYM

Encounter Date: 07/12/2019 13:10

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 037 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

Page 1 of 3

EFTA00073868

Inmate Name: EPSTEIN, JEFFREY EDWARD

Date of Birth: 01/20/1953

Encounter Date: 07/12/2019 13:10

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

## Pulmonary

<table border="1"><tr><td>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

Abdomen

Auscultation

Yes: Normo-Active Bowel S

<table border="1"><tr><td>Palpation</td></tr><tr><td>Yes: Within Normal Limits</td></tr></table>

<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>Magnesium Hydroxide Susp</td></tr></tbody></table>

<table><thead><tr><th>Order Date</th></tr></thead><tbody><tr><td>07/12/2019 13:10</td></tr></tbody></table>

<table><thead><tr><th>Prescriber Order</th></tr></thead><tbody><tr><td>30 CC Orally - Two Times a Day PRN x 2 day(s)</td></tr></tbody></table>

<table border="1"><tr><td>Indication:</td><td>Constipation, unspecified</td></tr><tr><td>MethylPREDNISolone Tab 4 MG(Dose Pack 21 tab)</td><td>07/12/2019 13:10</td></tr><tr><td>Indication:</td><td>Neuralgia and neuritis, unspecified</td></tr></table>

AS DIRECTED Orally - daily x 6 day(s)

## Disposition:

Generated 07/12/2019 14:20 by

Bureau of Prisons - NYM

Page 2 of 3

EFTA00073869

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/12/2019 13:10

Sex:
Provider:

M Race: WHITE

<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>

Follow-up at Sick Call as Needed

Other:

WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP.

# Patient Education Topics:

| Date Initiated | Format |

| :--- | :--- |

| 07/12/2019 | Counseling |

Handout/Topic

Diagnosis

Provider

<table><tr><td>Copay Required: No</td><td>Cosign Required: No</td></tr><tr><td>Telephone/Verbal Order: No</td><td></td></tr><tr><td colspan="2">Completed by Beaudouin, Robert MD on 07/12/2019 14:20</td></tr></table>

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



Page 039 of 148

Withheld pursuant to exemption

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

of the Freedom of Information and Privacy Act



Generated 07/12/2019 14:20 by

Bureau of Prisons - NYM

Page 3 of 3

EFTA00073870

# Bureau of Prisons
Health Services
See Amendment

Inmate Name: EPSTEIN, JEFFREY EDWARD

Sex:

Date of Birth: 01/20/1953

Encounter Date: 07/14/2019 17:36

Amendment made to this note by

on 07/14/2019 18:11.

Page 040 of 148

Withheld pursuant to exemption

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

freedom of Information and Privacy Ac

of the Freedom of Information and Privacy Act

Bureau of Prisons - NYM