EFTA00121320

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: 07/12/2019 13:10 | 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 QUE 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>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

EFTA00121321

| 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 |

## Exam:

## Eyes

**General**

Yes: PERRLA, Extraocular Movements Intact

## Pulmonary

## Cardiovascular

# Auscultation

Yes: Clear to Auscultation

<table border="1"><tr><td colspan="2">Auscultation</td></tr><tr><td colspan="2">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

<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 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:

## New Medication Orders:

<table><thead><tr><th>Rx#</th><th>Medication</th></tr></thead><tbody><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


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

<table border="1"><tr><td>Indication:</td><td>Constipation, unspecified</td></tr><tr><td>MethylIPREDNISolone 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

Page 2 of 3

MD

Bureau of Prisons - NYM

EFTA00121322

| 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

Telephone/Verbal Order:

Cosign Required: No

Completed by

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

Generated 07/12/2019 14:20 by

Page 3 of 3

MD

Bureau of Prisons - NYM

EFTA00121323

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: 07/12/2019 13:10 | 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 QUE 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>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

MD

Page 1 of 3

Bureau of Prisons - NYM

EFTA00121324

| 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 |

## Exam:

## Eyes

**General**

Yes: PERRLA, Extraocular Movements Intact

## Pulmonary

## Cardiovascular

# Auscultation

Yes: Clear to Auscultation

<table border="1"><tr><td colspan="2">Auscultation</td></tr><tr><td colspan="2">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

<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 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:

## New Medication Orders:

<table><thead><tr><th>Rx#</th><th>Medication</th></tr></thead><tbody><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


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

<table border="1"><tr><td>Indication:</td><td>Constipation, unspecified</td></tr><tr><td>MethylIPREDNISolone 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

Page 2 of 3

MD

Bureau of Prisons - NYM

EFTA00121325

| 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

Telephone/Verbal Order:

Cosign Required: No

Completed by

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

Generated 07/12/2019 14:20 by

Page 3 of 3

MD

Bureau of Prisons - NYM