EFTA00138976

# Bureau of Prisons Health Services Clinical Encounter

| Inmate Name: | EPSTEIN, JEFFREY EDWARD |
| :--- | :--- |
| Date of Birth: | Sex: M Race: WHITE |
| Encounter Date: 07/12/2019 13:10 | Provider: MD |
| | Reg #: 76318-054 |
| Facility: NYM |
| 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 43V. 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 LOCKLY 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><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

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MD



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