EFTA00139020

# Bureau of Prisons Health Services Clinical Encounter

| Inmate Name: | EPSTEIN, JEFFREY EDWARD |
| :--- | :--- |
| Date of Birth: | 01/20/1953 |
| Encounter Date: | 07/14/2019 17:36 |

| Sex: | M | Race: WHITE |
| :--- | :--- | :--- |
| Provider: | MD | Unit: Z05 |

Chronic Care - 14 Day Physician Eval encounter performed at Health Services.

## SUBJECTIVE:

## COMPLAINT 1

Chief Complaint: ENDO/LIPID

<table border="1"><tr><td>Subjective:</td><td>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</td></tr></table>

| Pain: | Yes |

| :--- | :--- |

<table><thead><tr><th colspan="2">Pain Assessment</th></tr></thead><tbody><tr><td>Date:</td><td>07/12/2019 13:25</td></tr><tr><td>Location:</td><td>Back-Middle</td></tr><tr><td>Quality of Pain:</td><td>Shooting</td></tr><tr><td>Pain Scale:</td><td>5</td></tr><tr><td>Intervention:</td><td>MEDROL DOSE PACK</td></tr><tr><td>Trauma Date/Year:</td><td></td></tr><tr><td>Injury:</td><td></td></tr><tr><td>Mechanism:</td><td></td></tr><tr><td>Onset:</td><td>5+ Years</td></tr><tr><td>Duration:</td><td>5+ Years</td></tr><tr><td>Exacerbating Factors:</td><td>NO EXERCISE</td></tr><tr><td>Relieving Factors:</td><td>MEDROL DOSE PACK</td></tr><tr><td>Reason Not Done:</td><td></td></tr><tr><td>Comments:</td><td></td></tr></tbody></table>

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

**Added to clinic(s):** Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid

## OBJECTIVE:

## Exam:

## General

## Appearance

<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 07/14/2019 18:11 by

MD

Bureau of Prisons - NYM



SDNY_00017384
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EFTA00139021

| Inmate Name: | EPSTEIN, JEFFREY EDWARD |

| :--- | :--- |

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

| Encounter Date: | 07/14/2019 17:36 |

Sex:

Provider:

<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>Z05</td></tr></table>

## Exam:

## Eyes

**General**

Yes: PERRLA, Extraocular Movements Intact

## Pulmonary

<table><tr><td>Auscultation</td></tr><tr><td>Yes: Clear to Auscultation</td></tr></table>

## Cardiovascular

<table border="1"><tr><td>Auscultation</td></tr><tr><td>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:



Rx#


<table><thead><tr><th>Medication</th></tr></thead><tbody><tr><td>Omega 3 (Vascepa) 1 GM Capsule</td></tr></tbody></table>

## Prescriber Order

<table><thead><tr><th>Order Date</th></tr></thead><tbody><tr><td>07/14/2019 17:36</td></tr></tbody></table>



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

<table><thead><tr><th>Frequency</th></tr></thead><tbody><tr><td>One Time</td></tr></tbody></table>

MD

<table><thead><tr><th>Due Date</th></tr></thead><tbody><tr><td>10/10/2019 00:00</td></tr></tbody></table>

Bureau of Prisons - NYM

**Priority**

Routine



SDNY_00017385

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EFTA00139022

| Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M | Race: WHITE | Reg #: 76318-054 |
| :--- | :--- | :--- | :--- |
| Date of Birth: 01/20/1953 | Provider: | MD | Facility: NYM |
| Encounter Date: 07/14/2019 17:36 | | | 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
Cosign Required: No
Telephone/Verbal Order: No

Generated 07/14/2019 18:11 by

MD



SDNY_00017386
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Bureau of Prisons - NYM