# Bureau of Prisons Health Services Clinical Encounter

<table border="1"><tr><td>Inmate Name:</td><td colspan="5">EPSTEIN, JEFFREY EDWARD</td><td>Reg #:</td><td>76318-054</td></tr><tr><td>Date of Birth:</td><td>01/20/1953</td><td>Sex:</td><td>M</td><td>Race:</td><td>WHITE</td><td>Facility:</td><td>NYM</td></tr><tr><td>Encounter Date:</td><td>07/12/2019 13:10</td><td>Provider:</td><td colspan="2"></td><td>MD</td><td>Unit:</td><td>Z05</td></tr></table>

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

## SUBJECTIVE:

COMPLAINT 1 Provider: MD

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 437. 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 border="1"><tr><td>Seen for clinic(s):</td><td>Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology</td></tr><tr><td>Added to clinic(s):</td><td>Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology</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>

No: Appears Obese

Generated 07/12/2019 14:20 by

Page 1 of 3

Bureau of Prisons - NYM

EFTA00110382

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

<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>

## Exam:

## Eyes

<table><tr><td>General</td></tr><tr><td>Yes: PERRLA, Extraocular Movements Intact</td></tr><tr><td>Pulmonary</td></tr><tr><td>Auscultation</td></tr><tr><td>Yes: Clear to Auscultation</td></tr><tr><td>Cardiovascular</td></tr><tr><td>Auscultation</td></tr><tr><td>Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2</td></tr><tr><td>No: M/R/G</td></tr><tr><td>Abdomen</td></tr><tr><td>Auscultation</td></tr><tr><td>Yes: Normo-Active Bowel Sounds</td></tr><tr><td>Palpation</td></tr><tr><td>Yes: Within Normal Limits</td></tr><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><tr><td>Neurologic</td></tr><tr><td>Cranial Nerves (CN)</td></tr><tr><td>Yes: Within Normal Limits</td></tr><tr><td>Motor System-General</td></tr><tr><td>Yes: Normal Exam</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>

## Prescriber Order

<table><tr><td>Indication: Constipation, unspecifiedMethylPREDNISolone Tab 4 MG (DosePack 21 tab)</td><td>07/12/2019 13:10</td></tr><tr><td>Indication: Neuralgia and neuritis, unspecified</td><td></td></tr></table>

30 CC Orally - Two Times a Day PRN x 2 day(s)



AS DIRECTED Orally - daily x 6 day(s)



## Disposition:

Generated 07/12/2019 14:20 by

Page 2 of 3

MD

Bureau of Prisons - NYM

EFTA00110383

| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M | Race: WHITE | Reg #: 76318-054 |
| :--- | :--- | :--- | :--- |
| Date of Birth: 01/20/1953 | | | Facility: NYM |
| Encounter Date: 07/12/2019 13:10 | Provider: E | MD | Unit: Z05 |

Follow-up at Sick Call as Needed

Other:

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

Patient Education Topics:

<table><thead><tr><th>Date Initiated</th><th>Format</th></tr></thead><tbody><tr><td>07/12/2019</td><td>Counseling</td></tr></tbody></table>

Handout/Topic

Diagnosis

Provider

Copay Required: No

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

Cosign Required: No

Telephone/Verbal Order:

Completed by

MD on 07/12/2019 14:20

Generated 07/12/2019 14:20 by

MD

Bureau of Prisons - NYM

Page 3 of 3

EFTA00110384

# Bureau of Prisons Health Services Clinical Encounter

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

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

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

## SUBJECTIVE:

<table border="1"><tr><td>Subjective:</td><td>66 YR OLD WHITE MALE WITH HX OFHYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS800,NOW431.STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDEMEDS DUE TO THEIR GI SIDE EFFECTSHX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAPMACHINE.STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED.STATES THE FBI LOKELY HASL4-L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THELOWER EXTREMITIES.SURGICAL HX:NONEMENTAL HEALTH HX:NONE</td></tr><tr><td>Pain:</td><td>Yes</td></tr></table>

<table><tr><td colspan="2">Pain Assessment</td></tr><tr><td>Date:</td><td>07/12/2019 13:25</td></tr><tr><td>Location:</td><td>Back-Middle</td></tr><tr><td>Quality of Pain:</td><td>Shooting</td></tr><tr><td>Pain Scale:</td><td>5</td></tr><tr><td>Intervention:</td><td>MEDROL DOSE PACK</td></tr><tr><td>Trauma Date/Year:</td><td></td></tr><tr><td>Injury:</td><td></td></tr><tr><td>Mechanism:</td><td></td></tr><tr><td>Onset:</td><td>5+ Years</td></tr><tr><td>Duration:</td><td>5+ Years</td></tr><tr><td>Exacerbating Factors:</td><td>NO EXERCISE</td></tr><tr><td>Relieving Factors:</td><td>MEDROL DOSE PACK</td></tr><tr><td>Reason Not Done:</td><td></td></tr><tr><td>Comments:</td><td></td></tr></table>

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

| :--- | :--- |

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

## OBJECTIVE:

## Exam:

## General

Appearance

<table><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>

Nutrition

No: Appears Obese

Generated 07/12/2019 14:20 by

Page 1 of 3

MD

Bureau of Prisons - NYM

EFTA00110385

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

<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>

## Exam:

## Eyes

<table><thead><tr><th></th><th>Description</th></tr></thead><tbody><tr><td colspan="2">General</td></tr><tr><td></td><td>Yes: PERRLA, Extraocular Movements Intact</td></tr><tr><td colspan="2">Pulmonary</td></tr><tr><td colspan="2">Auscultation</td></tr><tr><td></td><td>Yes: Clear to Auscultation</td></tr><tr><td colspan="2">Cardiovascular</td></tr><tr><td colspan="2">Auscultation</td></tr><tr><td></td><td>Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2</td></tr><tr><td></td><td>No: M/R/G</td></tr><tr><td colspan="2">Abdomen</td></tr><tr><td colspan="2">Auscultation</td></tr><tr><td></td><td>Yes: Normo-Active Bowel Sounds</td></tr><tr><td colspan="2">Palpation</td></tr><tr><td></td><td>Yes: Within Normal Limits</td></tr><tr><td colspan="2">Musculoskeletal</td></tr><tr><td colspan="2">Tibia / Fibula</td></tr><tr><td></td><td>No: Edema</td></tr><tr><td colspan="2">Back</td></tr><tr><td></td><td>Yes: Tenderness</td></tr><tr><td colspan="2">Neurologic</td></tr><tr><td colspan="2">Cranial Nerves (CN)</td></tr><tr><td></td><td>Yes: Within Normal Limits</td></tr><tr><td colspan="2">Motor System-General</td></tr><tr><td></td><td>Yes: Normal Exam</td></tr></tbody></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>

## Prescriber Order

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

30 CC Orally - Two Times a Day PRN x 2 day(s)

AS DIRECTED Orally - daily x 6 day(s)

## Disposition:

Generated 07/12/2019 14:20 by

Bureau of Prisons - NYM

Page 2 of 3

MD

EFTA00110386

| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M Race: WHITE | Reg #: 76318-054 |
| :--- | :--- | :--- |
| Date of Birth: 01/20/1953 | Facility: NYM |
| Encounter Date: 07/12/2019 13:10 | Unit: Z05 |

Follow-up at Sick Call as Needed

Other:

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

Patient Education Topics:

<table><thead><tr><th>Date Initiated</th><th>Format</th></tr></thead><tbody><tr><td>07/12/2019</td><td>Counseling</td></tr></tbody></table>

<table border="1"><tr><td>Handout/Topic</td></tr><tr><td>Diagnosis</td></tr></table>

Copay Required: No

Provider

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

Cosign Required: No

Telephone/Verbal Order:

Completed by

MD on 07/12/2019 14:20

Generated 07/12/2019 14:20 by

MD

Page 3 of 3

Bureau of Prisons - NYM