EFTA00139023 # Bureau of Prisons Health Services Clinical Encounter | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | :--- | :--- | | Date of Birth: | 01/20/1953 | | Encounter Date: | 07/12/2019 13:10 | | Sex: | M | Race: WHITE | | :--- | :--- | :--- | | Provider: | MD | 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 431. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS DUE 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 LOKELY HAS L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES. SURGICAL HX: NONE MENTAL HEALTH HX: NONE
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_00017387 Page 1 of 3 Bureau of Prisons - NYM EFTA00139024
Inmate Name:EPSTEIN, JEFFREY EDWARD
Date of Birth:01/20/1953
Encounter Date:07/12/2019 13:10
## Exam: ## Eyes **General** Yes: PERRLA, Extraocular Movements Intact ## Pulmonary ## Cardiovascular
Auscultation
Yes: Clear to Auscultation
Auscultation
Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2
No: M/R/G
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
Magnesium Hydroxide Susp
Order Date
07/12/2019 13:10
## Prescriber Order 30 CC Orally - Two Times a Day PRN x 2 day(s)
Indication:Constipation, unspecified
MethylIPREDNISolone Tab 4 MG(Dose Pack 21 tab)07/12/2019 13:10
Indication:Neuralgia and neuritis, unspecified
AS DIRECTED Orally - daily x 6 day(s) ## Disposition: Generated 07/12/2019 14:20 by SDNY_00017388 Page 2 of 3 Bureau of Prisons - NYM MD EFTA00139025 | Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M Race: WHITE | Reg #: 76318-054 | | :--- | :--- | :--- | | Date of Birth: 01/20/1953 | Facility: NYM | | Encounter Date: 07/12/2019 13:10 | Unit: Z05 | Follow-up at Sick Call as Needed ## Other: WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP. # Patient Education Topics: | Date Initiated | Format | | :--- | :--- | | 07/12/2019 | Counseling |
Handout/Topic
Diagnosis
Provider | Copay Required: No | Cosign Required: No | | :--- | :--- | | Telephone/Verbal Order: No | | Completed by Beaudouin, Robert MD on 07/12/2019 14:20
Outcome
Verbalizes
Understanding
Generated 07/12/2019 14:20 by MD SDNY_00017389 Page 3 of 3 Bureau of Prisons - NYM EFTA00139026 # Bureau of Prisons Health Services Clinical Encounter | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | :--- | :--- | | Date of Birth: | 01/20/1953 | | Encounter Date: | 07/12/2019 13:10 | | Sex: | M | Race: WHITE | | :--- | :--- | :--- | | Provider: | MD | 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 431. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS DUE TO THEIR GI SIDE EFFECTS. HX OF OBSTRUCTUVE 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 LOKELY HAS L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES. SURGICAL HX: NONE MENTAL HEALTH HX: NONE
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_00017390 Page 1 of 3 Bureau of Prisons - NYM EFTA00139027
Inmate Name:EPSTEIN, JEFFREY EDWARD
Date of Birth:01/20/1953
Encounter Date:07/12/2019 13:10
## Exam: ## Eyes **General** Yes: PERRLA, Extraocular Movements Intact ## Pulmonary ## Cardiovascular
Auscultation
Yes: Clear to Auscultation
Auscultation
Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2
No: M/R/G
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
Magnesium Hydroxide Susp
Order Date
07/12/2019 13:10
## Prescriber Order 30 CC Orally - Two Times a Day PRN x 2 day(s)
Indication:Constipation, unspecified
MethylIPREDNISolone Tab 4 MG(Dose Pack 21 tab)07/12/2019 13:10
Indication:Neuralgia and neuritis, unspecified
AS DIRECTED Orally - daily x 6 day(s) ## Disposition: Generated 07/12/2019 14:20 by SDNY_00017391 Page 2 of 3 Bureau of Prisons - NYM MD EFTA00139028 | Inmate Name: EPSTEIN, JEFFREY EDWARD | Sex: M Race: WHITE | Reg #: 76318-054 | | :--- | :--- | :--- | | Date of Birth: 01/20/1953 | Facility: NYM | | Encounter Date: 07/12/2019 13:10 | Unit: Z05 | Follow-up at Sick Call as Needed ## Other: WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP. # Patient Education Topics: | Date Initiated | Format | | :--- | :--- | | 07/12/2019 | Counseling |
Handout/Topic
Diagnosis
Provider | Copay Required: No | Cosign Required: No | | :--- | :--- | | Telephone/Verbal Order: No | | Completed by Beaudouin, Robert MD on 07/12/2019 14:20
Outcome
Verbalizes
Understanding
Generated 07/12/2019 14:20 by MD Bureau of Prisons - NYM SDNY_00017392 Page 3 of 3