EFTA00121317

Bureau of Prisons Health Services Clinical Encounter

| 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 |

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

<table border="1"><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 07/14/2019 18:11 by

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MD

Bureau of Prisons - NYM

EFTA00121318

| 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 |

## Eyes

## Exam:

**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</td></tr><tr><td>No: M/R/G</td></tr></table>

## Abdomen

<table><tr><td>Auscultation</td><td>Yes: Normo-Active Bowel Sounds</td></tr><tr><td>Palpation</td><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>

# Neurologic

## Cranial Nerves (CN)

Yes: Within Normal Limits

## Motor System-General

Yes: Normal Exam

## ASSESSMENT:

<table><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:

## New Medication Orders:



Rx#


# Medication

Omega 3 (Vascepa) 1 GM Capsule

<table><thead><tr><th>Order Date</th></tr></thead><tbody><tr><td>07/14/2019 17:36</td></tr></tbody></table>

## 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:**

erated 07/14/2019 18:11 by

<table><tr><td>Frequency</td></tr><tr><td>One Time</td></tr></table>

Generated 07/14/2019 18:11 by

MD

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

**Priority**

Routine

Bureau of Prisons - NYM

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EFTA00121319

| Inmate 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-Ep B surface Ab
- Lab Tests-H-Ep B surface Ag
- Lab Tests-H-Ep 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 F/U. | | |
| 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

Generated 07/14/2019 18:11 by

MD

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Bureau of Prisons - NYM