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:¶
| 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 |
Page 1 of 3¶
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¶
| Auscultation |
| Yes: Clear to Auscultation |
Cardiovascular¶
| Auscultation |
| Yes: Regular Rate and Rhythm(RRR), Normal S1 and S2 No:M/R/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)¶
Yes: Within Normal Limits¶
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 |
Prescriber Order¶
| Prescriber Order |
|---|
| TAKE 2 CAPS Orally - Two Times a Day x 180 day(s) -- TAKE WITH FOOD. |
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¶
| Frequency |
|---|
| One Time |
MD¶
Bureau of Prisons - NYM¶
| Due Date |
|---|
| 10/10/2019 00:00 |
Priority¶
Routine¶
Page 2 of 3¶
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¶
Page 3 of 3¶
Bureau of Prisons - NYM¶
EFTA00110381¶