EFTA00138973¶
Bureau of Prisons Health Services Clinical Encounter¶
| Inmate Name: | EPSTEIN, JEFFREY EDWARD |
|---|---|
| Date of Birth: | Sex: M Race: WHITE |
| Encounter Date: 07/14/2019 17:36 | Provider: MD |
| Reg #: 76318-054 | |
| Facility: NYM | |
| Unit: Z05 |
Chronic Care - 14 Day Physician Eval encounter performed at Health Services.¶
SUBJECTIVE:¶
COMPLAINT 1¶
| Subjective: | 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 CPAMACHINE. 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 |
| 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¶
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¶
Generated 07/14/2019 18:11 by¶
MD¶
Bureau of Prisons - NYM¶
SDNY_00017337¶
Page 1 of 3¶
Page 294¶
EFTA00138974¶
| Inmate Name: | EPSTEIN, JEFFREY EDWARD |
|---|---|
| Date of Birth: | Sex: M Race: WHITE |
| Encounter Date: 07/14/2019 17:36 | Provider: MD |
| Reg #: | 76318-054 |
| Facility: | NYM |
| Unit: | Z05 |
Exam:¶
Eyes¶
General¶
Yes: PERRLA, Extraocular Movements Intact¶
Pulmonary¶
| Auscultation |
| Yes: Clear to Auscultation |
Cardiovascular¶
Abdomen¶
| Auscultation |
| Yes: Regular Rate and Rhythm(RRR), Normal S1 and S2 No:M/R/G |
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¶
TAKE 2 CAPS Orally - Two Times a Day x 180 day(s) — TAKE WITH FOOD.¶
New Laboratory Requests:¶
Indication: Hyperlipidemia, unspecified¶
Details¶
Lab Tests-H-Hemoglobin A1C¶
Lab Tests-L-Lipid Profile¶
Additional Information:¶
erated 07/14/2019 18:11 by¶
| Frequency |
|---|
| One Time |
MD¶
| Due Date |
|---|
| 10/10/2019 00:00 |
Bureau of Prisons - NYM¶
Priority¶
Routine¶
SDNY_00017338¶
Page 2 of 3¶
Page 295¶
EFTA00138975¶
| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M | Race: WHITE | Reg #: 76318-054 |
|---|---|---|---|
| Date of Birth: | Facility: NYM | ||
| Encounter Date: 07/14/2019 17:36 | Provider: | MD | 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 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¶
SDNY_00017339 Page 3 of 3¶
Bureau of Prisons - NYM¶
page 296¶