EFTA00134775

# 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: 07/30/2019 11:12 | Provider: | | Unit: Z01 |

Chronic Care - Chronic Care Clinic encounter performed at Health Services.

## SUBJECTIVE:

Chief Complaint: Other Problem

<table><tr><td>Subjective:</td><td>PATIENT WAS REFERRED BY THE WARDEN FOR EVALUATION.

PATIENT REPORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO REPORTS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STATES THE NUMBNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING.

HE DENIES RIGHT SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OR SWALLOWING.

HE REPORTS NOCTURIA OF ABOUT 5 TIMES., HE DENIES DYSURIA.

HE REPORTS H OF KIDNEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL.

HE AHS A HX OF SLEEP APNEA AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HERE SINCE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE RECEIVED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT..

HE REPORT OTHER NON-MEDICAL ISSUES.

STATES HE FEELS OTHERWISE PINE.</td></tr><tr><td>Pain:</td><td>Not Applicable</td></tr></table>

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

## OBJECTIVE:

## Pulse:

## Respirations:

## Blood Pressure:





SaO2:


## Weight:



Generated 07/30/2019 14:05 by

Bureau of Prisons - NYM

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SDNY_00001032


| EFTA_00000241 |
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EFTA00134776

## Exam:

### General

#### Affect
Yes: Cooperative

#### 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

#### Nutrition
No: Appears Obese

#### Pulmonary

#### Auscultation
Yes: Clear to Auscultation

#### Cardiovascular

#### Auscultation
Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2
No: MIR/G

#### Musculoskeletal

#### Tibia / Fibula
No: Edema

#### Neurologic

#### Cranial Nerves (CN)
Yes: Within Normal Limits

#### Motor System-General
Yes: Normal Exam

#### Motor System-Strength
Yes: Normal Muscular Strength

## ASSESSMENT:

Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current

Constipation, unspecified, K5900 - Current

Essential (primary) hypertension, I10 - Current - BY HX.

Hyperlipidemia, unspecified, E785 - Current

Low back pain, M545 - Current

Neuralgia and neuritis, unspecified, M792 - Current

Prediabetes, R7303 - Current

Sleep apnea, G4730 - Current

## PLAN:

New Medication Orders:

<table><tr><td>Reg #:</td><td>76318-054</td></tr><tr><td>Facility:</td><td>NYM</td></tr><tr><td>Unit:</td><td>Z01</td></tr></table>

Generated 07/30/2019 14:05 by

Bureau of Prisons - NYM

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SDNY_00001033


EFTA00134777

| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M | Race: WHITE | Reg #: 76318-054 |
| :--- | :--- | :--- | :--- |
| Date of Birth: 01/20/1953 | | | Facility: NYM |
| Encounter Date: 07/30/2019 11:12 | Provider: | | Unit: Z01 |

<table><thead><tr><th>Rx#</th><th>Medication</th><th>Order Date</th><th>Prescriber Order</th></tr></thead><tbody><tr><td>121836-NYM</td><td>methylIPREDNISolone 4 MG Tab (21 count Pack)</td><td>07/30/2019 11:12</td><td>Take the tablet by mouth as directed x 6 day(s)</td></tr><tr><td colspan="4">Indication: Neuralgia and neuritis, unspecified</td></tr></tbody></table>

<table><thead><tr><th>Details</th><th>Frequency</th><th>Due Date</th><th>Priority</th></tr></thead><tbody><tr><td>Lab Tests - Short List-General-CBC w/diff</td><td>One Time</td><td>08/01/2019 00:00</td><td>Routine</td></tr><tr><td>Lab Tests-P-PSA, Total</td><td></td><td></td><td></td></tr><tr><td>Lab Tests-U-Uric Acid</td><td></td><td></td><td></td></tr><tr><td>Lab Tests - Short List-General-Comprehensive Metabolic Profile (CMP)</td><td></td><td></td><td></td></tr><tr><td>Lab Tests-U-Urinalysis w/Reflex to Microscopic New Radiology Request Orders:</td><td></td><td></td><td></td></tr></tbody></table>

<table><thead><tr><th>Details</th><th>Frequency</th><th>End Date</th><th>Due Date</th><th>Priority</th></tr></thead><tbody><tr><td>General Radiology-Spine / Cervical-General</td><td>One Time</td><td></td><td>08/29/2019</td><td>Routine</td></tr></tbody></table>

Specific reason(s) for request (Complaints and findings):

66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUIMBNESS FOR 2-3 MINUTES 3 DAYS AGO. PLEASE PERFORM C SPINE SERIES

## Disposition:

Follow-up at Sick Call as Needed

## Patient Education Topics:

<table><thead><tr><th>Date Initiated</th><th>Format</th></tr></thead><tbody><tr><td>07/30/2019</td><td>Counseling</td></tr></tbody></table>

Handout/Topic

Access to Care

| 07/30/2019 | Counseling |

| :--- | :--- |

Plan of Care



<table><tr><td>Copay Required: No</td><td>Cosign Required: No</td></tr><tr><td>Telephone/Verbal Order: No</td><td></td></tr><tr><td>Completed by</td><td>on 07/30/2019 14:05</td></tr></table>

Generated 07/30/2019 14:05 by

Bureau of Prisons - NYM

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SDNY_00001034






| EFTA_00000243 |

| :--- | :--- |

This is a simple Markdown document with no headings, paragraphs, or tables. It contains just one line of text.

EFTA00134778

# 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: 07/30/2019 11:12 | Provider: | | Unit: Z01 |

Chronic Care - Chronic Care Clinic encounter performed at Health Services.

## SUBJECTIVE:

Chief Complaint: Other Problem

<table><tr><td>Subjective:</td><td>PATIENT WAS REFERRED BY THE WARDEN FOR EVALUATION.

PATIENT REPORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO REPORTS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STATES THE NUMBNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING.

HE DENIES RIGHT SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OR SWALLOWING.

HE REPORTS NOCTURIA OF ABOUT 5 TIMES., HE DENIES DYSURIA.

HE REPORTS H OF KIDNEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL.

HE AHS A HX OF SLEEP APNEA AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HERE SINCE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE RECEIVED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT..

HE REPORT OTHER NON-MEDICAL ISSUES.

STATES HE FEELS OTHERWISE FINE.</td></tr><tr><td>Pain:</td><td>Not Applicable</td></tr></table>

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

## OBJECTIVE:

## Pulse:

## Respirations:

## Blood Pressure:



SaO2:


## Weight:

<table><thead><tr><th>Date</th><th>Time</th><th>Lbs</th><th>Kg</th><th>Waist Circum.</th><th>Provider</th></tr></thead></table>

Generated 07/30/2019 14:05 by

Page 1 of 3



SDNY_00001035


EFTA_00000244

EFTA00134779

| Inmate Name: | EPSTEIN, JEFFREY EDWARD |

| :--- | :--- |

| Date of Birth: | 01/20/1953 |

| Encounter Date: | 07/30/2019 11:12 |

<table border="1"><tr><td>Sex:</td><td>M</td><td>Race:</td><td>WHITE</td></tr><tr><td>Provider:</td><td colspan="3"></td></tr></table>

<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>Z01</td></tr></table>

<table><thead><tr><th>Date</th><th>Time</th><th>Lbs</th><th>Kg</th><th>Waist Circum.</th><th>Provider</th></tr></thead><tbody><tr><td>07/30/2019</td><td>09:30 NYM</td><td>194.2</td><td>88.1</td><td></td><td></td></tr></tbody></table>

## Exam:

## General

## Affect

## Appearance



Yes: Cooperative



## ASSESSMENT:

<table><tr><td>Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current</td></tr><tr><td>Constipation, unspecified, K5900 - Current</td></tr><tr><td>Essential (primary) hypertension, I10 - Current - BY HX.</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>Prediabetes, R7303 - Current</td></tr><tr><td>Sleep apnea, G4730 - Current</td></tr></table>

## PLAN:

<table><tr><td colspan="2">New Medication Orders:</td></tr><tr><td>Rx#</td><td>Medication</td></tr></table>



Order Date



Generated 07/30/2019 14:05 by

Prescriber Order

Bureau of Prisons - NYM

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SDNY_00001036




EFTA_00000245







EFTA00134780

| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M | Race: WHITE | Reg #: 76318-054 |
| :--- | :--- | :--- | :--- |
| Date of Birth: 01/20/1953 | Provider: | | Facility: NYM |
| Encounter Date: 07/30/2019 11:12 | | | Unit: Z01 |

<table><thead><tr><th>Rx#</th><th>Medication</th><th>Order Date</th><th>Prescriber Order</th></tr></thead><tbody><tr><td>121836-NYM</td><td>methylPREDNISolone 4 MG Tab (21 count Pack)</td><td>07/30/2019 11:12</td><td>Take the tablet by mouth as directed x 6 day(s)</td></tr><tr><td colspan="4">Indication: Neuralgia and neuritis, unspecified</td></tr></tbody></table>

<table><thead><tr><th>Details</th><th>Frequency</th><th>End Date</th><th>Due Date</th><th>Priority</th></tr></thead><tbody><tr><td>General Radiology-Spine / Cervical-General</td><td>One Time</td><td></td><td>08/29/2019</td><td>Routine</td></tr></tbody></table>

66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUIMBNESS FOR 2-3 MINUTES 3 DAYS AGO.

PLEASE PERFORM C SPINE SERIES

## Disposition:

Follow-up at Sick Call as Needed

## Patient Education Topics:

<table border="1"><tr><td>Date Initiated</td><td>Format</td><td>Handout/Topic</td></tr><tr><td>07/30/2019</td><td>Counseling</td><td>Access to Care</td></tr></table>

07/30/2019 Counseling



<table><tr><td>Copay Required: No</td><td>Cosign Required: No</td></tr><tr><td>Telephone/Verbal Order: No</td><td></td></tr><tr><td>Completed by</td><td>on 07/30/2019 14:05</td></tr></table>

Generated 07/30/2019 14:05 by

Bureau of Prisons - NYM

Page 3 of 3



SDNY_00001037