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¶