EFTA00033825.pdf

Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Race: WHITE Encounter Date: 07/12/2019 13:10 Provider: Reg SI: 76318-054 Facility: NYM Unit: Z05 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDO/LIPID Subjective: 66 YR OL HITE MALE WITH FIX OF HYPERT CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS • EIR GI SIDE EFFECTS. HX OF O UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. it HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE : Y HAS L4 - LS SEVERE SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMI S SURGICAL HX: NONE MENTAL HEALTH HX: Pain: Yes Pain Assessment Date: 07/1 2/2019 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 Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed. Dyspneic. Appears in Pain. Writhing in Pain, Pate. Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt. Acutely 111 Nutrition No: Appears Obese Generated 07/7212019 14. 20 by Bureau of Prisons • NYM Page I of 3 CONFIDENTIAL SDNY_00009419 EFTA00033825 Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Dale: 07/12/2019 13:10 Provider M Race: WHITE Reg #: 76318-054 Facility: NYM Unit: Z05 Exam: Eyes General Yes: PERRLA, Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal S1 and S2 No: M/R/G Abdomen Auscultation Yes: Normo-Active B Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back Yes: Tenderness ithi Neurologic Cranial Nerves (CN) Yes: W ASSESSMENT: Constipation, unspecified, K5900 - Current 4 74 0.1)0 Motor System-General n Normal Limits Yes: Normal Exam Hyperlipidemia, unspecified, E785 - Current Low back pain. M545 - Current Neuralgia and neuritis, unspecified, M792 - Current >e, Sleep apnea, G4730 - Current PLAN: New Medication Orders: Rx# Medication Qrtes Epa Magnesium Hydroxide Susp 07/1 2/2019 13:10 Indication: Constipation, unspecified MethyiPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 Pack 21 tab) Indication: Neuralgia and neuritis. unspecified Disposition: Generated 07/1 22019 14:20 by Prescriber Order" 30 CC Orally - Two Times a Day PRN x 2 day(s) AS DIRECTED Orally - daily x 6 day(s) Bureau of Prisons - NYM Page 2 of 3 CONFIDENTIAL SDNY_00009420 EFTA00033826 Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/12/2019 13:10 Provider: I Reg #: 76318-054 Facility: NYM Unit: Z05 Follow-up at Sick Call as Needed Other: WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP. Patient Education Topics: Pate Initiates'. Format Han ~UTop! 07/12/2019 Counseling Diagnosis Copay Required: No Cosign Required: No TelephoneNerbal Order: Completed by Beaudouin. n 07/12/2019 14:20 Generated 07/12/2019 14 20 by Provider Outcome Verbalizes Understanding Bureau of Prisons NYM Page 3 of 3 CONFIDENTIAL SDNY 00009421 EFTA00033827 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN. JEFFREY EDWARD Reg tit: 76318.054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: Unit: Z05 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDO/LIPID Subjective: 66 YR OL HITE MALE WITH HX OF HYPERT; CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS • EIR GI SIDE EFFECTS. HX OF O 4 UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. -I, 1-Nr* HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE a Y HAS L4 - L5 SEVERE SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMI SURGICAL FIX: NONE MENTAL HEALTH FIX: 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 Appearance 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 III Nutrition No: Appears Obese Generated 07112,2019 14 20 by Bureau of Prisons - NYM Page 1 of 3 CONFIDENTIAL SDNY 00009422 EFTA00033828 Inmate Name: EPSTEIN, JEFFREY EDWARD Dale of Birth: 01/20/1953 Sex: Encounter Date: 07/12/2019 13:10 Provider M Race: WHITE Reg #: 76318-054 Facility: NYM Unit: 205 Exam: Eyes General Yes: PERRLA, Exlraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal S1 and S2 No: WR/G Abdomen Auscultation Yes: Normo-Active B 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 Indication: Constipation, unspecified MethyIPREDNISolone Tab 4 MG ( Dose Pack 21 tab) Indication: Neuralgia and neuritis, unspecified Disposition: Corer:nod 01:17, 2019 1420 by Order Date 07/12/2019 13:10 07/12/2019 13:10 Bureau of Prisons - NYM aescriber Order 30 CC Orally - Two Times a Day PRN x 2 day(s) AS DIRECTED Orally - daily x 6 day(s) Page 2 of 3 CONFIDENTIAL SDNY 00009423 EFTA00033829 Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/12/2019 13:10 Reg #: 76318.054 Sex: M Race: WHITE Facility: NYM Provider: El 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 Handout/Tonic 07/12/2019 Counseling Diagnosis Copay Required: No TelephoneNerbal Order: Cornpteled CI Generated 07/12/2019 14 20 by Cosign Required: No n 07/12/2019 14:20 Bureau of Prisons NYM Provider Outcome Verbalizes Understanding Page 3 of 3 CONFIDENTIAL SDNY_00 009424 EFTA00033830 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/14/2019 17:36 Facility: NYM Amendment made to this note by on 07114/2019 18:11. &mftwoflhiumis.NYM CONFI