EFTA00110378

# Bureau of Prisons Health Services Clinical Encounter

| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M Race: WHITE | Reg #: 76318-054 |
| :--- | :--- | :--- |
| Date of Birth: 01/20/1953 | Facility: NYM |
| Encounter Date: 07/14/2019 17:36 | Unit: Z05 |

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

## SUBJECTIVE:

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 OBSTRUCTIVE 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

Location: Back-Middle

Quality of Pain: Shooting

Pain Scale: 5

Intervention: MEDROL DOSE PACK

Trauma Date/Year:

Injury:

Mechanism:

Onset: 5+ Years

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

<table border="1"><tr><td>Appearance</td></tr><tr><td>Yes: Appears Well, Alert and Oriented x 3</td></tr><tr><td>No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely Ill</td></tr></table>

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MD

Bureau of Prisons - NYM

EFTA00110379

| Inmate Name: | EPSTEIN, JEFFREY EDWARD |
| :--- | :--- |
| Date of Birth: | 01/20/1953 |
| Encounter Date: | 07/14/2019 17:36 |

| Sex: | M | Race: WHITE |
| :--- | :--- | :--- |
| Provider: | MD | Unit: Z05 |

## Exam:

## Eyes

**General**

Yes: PERRLA, Extraocular Movements Intact

## Pulmonary

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

## Cardiovascular

<table border="1"><tr><td>Auscultation</td></tr><tr><td>Yes: Regular Rate and Rhythm(RRR), Normal S1 and S2 No:M/R/G</td></tr></table>

## Abdomen

Auscultation

Yes: Normo-Active Bowel Sounds

## Palpation

Yes: Within Normal Limits

# Musculoskeletal

## Tibia / Fibula

No: Edema

## Back

Yes: Tenderness

# Neurologic

## Cranial Nerves (CN)

Yes: Within Normal Limits

## Motor System-General

Yes: Normal Exam

## 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>

## Prescriber Order

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

## Indication: Hyperlipidemia, unspecified

New Laboratory Requests:

Details

Lab Tests-H-Hemoglobin A1C

Lab Tests-L-Lipid Profile

Additional Information:

Generated 07/14/2019 18:11 by

<table><thead><tr><th>Frequency</th></tr></thead><tbody><tr><td>One Time</td></tr></tbody></table>

MD

Bureau of Prisons - NYM

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

**Priority**

Routine

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EFTA00110380

| Innate Name: EPSTEIN, JEFFREY EDWARD | Sex: M | Race: WHITE | Reg #: 76318-054 |
| :--- | :--- | :--- | :--- |
| Date of Birth: 01/20/1953 | Provider: | MD | Facility: NYM |
| Encounter Date: 07/14/2019 17:36 | | | 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

Schedule:
Activity | Date Scheduled | Scheduled Provider
------- | --- | ---
Clinical Encounter | 07/24/2019 00:00 | Optometrist
66 YR OLD MALE FOR ROUTINE SCREENING.
Chronic Care Visit | 01/07/2020 00:00 | Mid-Level Provider
6 MONTH FU.
Chronic Care Visit | 07/01/2020 00:00 | Physician 01

Other:
PENDING EKG AND FOBT. CXR WAS REFUSED.

Patient Education Topics:
Date Initiated Format Handout/Topic Provider Outcome
07/14/2019 Counseling Diagnosis Verbalizes Understanding

Copay Required: No
Telephone/Verbal Order: No

Completed by MD on 07/14/2019 18:11

Generated 07/14/2019 18:11 by

MD

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Bureau of Prisons - NYM

EFTA00110381