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:¶
| Seen for clinic(s): | Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology |
| Added to clinic(s): | Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology |
OBJECTIVE:¶
Exam:¶
General¶
| 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 07/12/2019 14:20 by¶
MD¶
SDNY_00017340¶
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