EFTA00059443.pdf

Bureau of Prisons Health Services Cosign/Review Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Race: WHITE 01/20/1953 Sex: M Date of Birth: MLP Facility: N M 07/09/ 2019 12:35 Provid er: Encounter Date: Cosigned by MD on 07/11/2019 22:41. Burew W ftilscm - WM EFTA00059443  Bureau of Prisons Health Services Inmate Local Hospital Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD SENSITIVE BUT UNCLASSIFIED — This information is confidential and must be appropriately safeguarded. Transfer To: Transfer Date: 08/10/2019 Health Problems Health Problem atatua Hyperlipldemia, unspecified Current HYPERTRIGLYCERIDEMIA Sleep apnea Current Essential (primary) hypertension Current BY HX. Constipation, unspecified Current Low back pain Current Neuralgia and neuritis, unspecified Current No Diagnosis Current Prediabetes Current Injury, unspecified Current R/O self Inflicted injuries. Body mass index (BMI) 27.0-27.9, adult Current In lorded. Medications: All medications to be continued until evaluated by a physician unless otherwise Bolded drugs required for transport. ily for 30 days Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take one capsule (100 MG) by mouth twice 01/22/2020 SIG: Take one capsule (100 MG) twice daily by th with plenty Docusate Sodium 100 MG Cap Exp: of water th twice Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML Exp: 10/28/2019 SIG: shake well take 10mI by daily AS NEEDED Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by uth with food OTCs: Listing of all known OTCs this inmate is currently taking. None Pending Appointments lima Activity Provider Dale 07/24/2019 00:00 Clinical Encounter Optometrist 01/07/2020 00:00 Chronic Care Visit Mid-Level Provider 07/01/2020 00:00 Chronic Care Visit Physician 01 07/09/2020 00:00 PPD Administration Nurse Pending Non-Medication Orders: Order Order Date Frequency Dualism Retails EKG 07/06/2019 One Time 66 y/o male Focal Occult Blood 07/06/2019 One Time 3 different stools TB Clearance: Yes Last PPD Date: 07/09/2019 Induration: 0mm Last Chest X-Ray Date: Results: TB Treatment Sx free for 30 days: Yes TB Follow-up Recommended: No Sickle Cell: Sickle Cell Trait/Disease: No RN Bureau of Prisons - NYM Page 1 of 2 Generated 08/10/2019 07:00 by EFTA00059444 Reg 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD d. SENSITIVE BUT UNCLASSIFIED — This Won-nation Is confidential and must be appropriately safeguard Limitations:Restrictions/Diets: Cell: lower bunk — 10/09/2019 Cleared for Food Service: Yes Other diet restrictions: FISH ALLERGIES. — 07/30/2020 Comments: Allergies No Known Allergies Devices / Equipment C-Pap Travel: Direct Travel: No Travel Restrictions: None UNIVERSAL PRECAUTIONS OBSERVED WHEN TRANSPORTING ANY INMATE: Transfer From Institution: NEW YORK MCC Phone Number. 6468366300 Address 1: 150 PARK ROW Address 2: City/State/Zip: NEW YORK, New York 10007 Namerfltle of Person Completing Form: RN Dal 08/10/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 DOB: 01/20/1953 Generated 08110/2019 07:00 by RN Bureau al Prisons - NNW Page 2 of 2 EFTA00059445  Bureau of Prisons Health Services Vitals All Begin Date: 07/07/2019 End Date: 08/10/2019 Rog #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Temperature: Data Tiffin Fahrenheit Celsitot Location Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral .MLP Orig Entered: 07/24/2019 13:14 EST MLP 07/23/2019 06:30 NYM 97.5 36.4 Oral .MLP Orig Entered: 07/23/2019 08:33 EST MLP 07/09/2019 12:49 NYM 97.3 36.3 Oral .MLP Orig Entered: 07/09/2019 12:51 EST MLP Pulse: Time Rate Per Minute I ocation Rhythm Provider 12lita 94 MD 07/30/2019 13:02 Orig Entered: 07/30/2019 13:04 EST MD 88 Via Machine MD 07/30/2019 09:40 Orig Entered: 07/30/2019 13:04 EST MO 87 Via Machine MD 07/30/2019 09:30 Orly Entered: 07/30/2019 12:59 EST MD 81 RN 07/28/2019 20:28 Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 82 Orig Entered: 07/28/2019 06:58 EST RN 83 Via Machine Regular 7! RN 07/24/2019 13:12 Orly Entered: 07/24/2019 13:14 EST . MLP 92 Via Machine Regular .MLP 07/23/2019 06:30 Orig Entered: 07/23/2019 08:33 EST . MLP 82 Via Machine Regular .MLP 07/09/2019 12:49 Orig Entered: 07/09/2019 12:51 EST MLP Respirations: Bata Inn Rate Per Minute Provider 07/30/2019 09:30 NYM 12 MD Orly Entered: 07/30/2019 12:59 EST MD 07/28/2019 20:28 NYM 14 RN Orlg Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 NYM 14 RN Orig Entered: 07/28/2019 06:58 EST RN 07/23/2019 06:30 NYM IIIWMLP Orly Entered: 07/23/2019 08:33 EST . MLP 07109/2019 12:49 NYM 16 . MLP Orig Entered: 07/09/2019 12:51 EST . MLP Bureau of Prisons - NYM Pogo 1 or 3 Generated O8V10/2019 11:02 by EFTA00059446 Begin Date: 07/07/2019 End Date: 08/10/2019 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: Blood Pressure: Value ) °cation Position Cuff Size provider Date lima Left Arm Standing Beaudouin, Robert MD 07/30/2019 13:02 NYM 114/84 Orig Entered: 07/30/2019 13:04 EST MD Right Arm Standing EMINIMMD 07/30/2019 09:40 NYM 125/60 Orig Entered: 07/30/2019 13:04 EST MO Left Ann Sitting MIMI"( MD 07/30/2019 09:30 NYM 108/86 Orig Entered: 07/30/201912:59 EST MD RN 07/28/2019 20:28 NYM 157/91 -U Orig Entered: 07/28/2019 20:29 EST RN RN 07/28/2019 06:57 NYM 138/80 Orig Entered: 07/28/2019 06:58 EST RN Right Arm Sitting Adult-regular MLP 07/24/2019 13:12 NYM 132/89 Orig Entered: 07/24/2019 13:14 EST MLP 07/23/2019 06:30 NYM 140/85 Right AIM Sitting Adult-regular MLP Orig Entered: 07/23/2019 08:33 EST MLP 07/09/2019 12:49 NYM 117/66 Right Arm Sitting Adult-regular Ma MLP Orig Entered: 07/09/2019 12:51 EST MLP Blood Glucose: Thus Time Value imgldll Tyne Regular insulin provider 08/04/2019 08:30 156 Non-Fasting RN Ortg Entered: 08/04/2019 09:08 EST RN 08/02/2019 06:30 97 Non-Fasting MLP Orig Entered: 08/02/2019 08:16 EST MLP 08/01/2019 06:30 103 Non-Fasting MLP Orig Entered: 08/01/2019 09:00 EST alla MLP 07/31/2019 06:15 108 Non-Fasting MLP Orig Entered: 07/31/2019 08:36 EST Ma MLP Sa02: Nit /1mi ValuerAl Ak provider 07/30/2019 09:30 NYM 98 Room Air MD Orig Entered: 07/30/2019 12:59 EST MD 07/28/2019 20:28 NYM 98 RN Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 08:57 NYM 98 RN Orig Entered: 07/28/2019 06:58 EST RN 07/24/2019. 13:12 NYM 96 Room Air . MLP Orig Entered: 07/24/2019 13:14 EST =M. MLP 07/23/2019 06:30 NYM 96 Room Air MLP Orig Entered: 07/23/2019 08:33 EST MLP 07/09/2019 12:49 NYM 97 Room Air ■ MLP Orig Entered: 07/09/2019 12:51 EST MLP Height Generated 08/10/2019 11:02 by Bureau of Parsons NYM Page 2 of 3 EFTA00059447 Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Data II= Inches Cm Provider 07/09/2019 12:49 NYM 70.0 * 177.8 MLP Orig Entered: 07/09/201912:51 EST a MLP Weight: D.A.Ltt Emit 1n Kg Weicc .In1 Provider 07/30/2019 09:30 NYM 194.2 88.1 ~nip Orig Entered: 07/30/2019 12:59 EST MD 07/09/2019 12:49 NYM 194.4 88.2 MLP Orig Entered: 07/09/2019 12:51 EST a MLP Generaled 08/10/2019 11:02 by Bureau of Prisons - NYM Pass Set 3 EFTA00059448  Bureau of Prisons Health Services PPDs Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD j,ocation Provider Reading• Induration 07/06/2019 21:39 Right Forearm C 07/09/2019 12:47 0 mm INS MLP Orig Entered: 07/06/2019 21:43 EST Odg Entered: 07109/2019 12:47 EST MI MLP Total: 1 Generated 08/10/2019 11:02 by RNAOP/IDC Bureau of Prisons - NYM Page I 011 EFTA00059449  JULY 2019 76316454 EPSTEIN, JEFFREY Medication Administration Record Medication Orders Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 rm • ob. 07r10/19 PRN 1421 Infect neulz: Insulin st bcute-toousty per Exp. Dab altding ocr,..:J: bock° Cary ^•p'J Ilna^• for 7 07(31119 days 1001 NYM 122148- NM/ tuff) Reg (10 IC)1CR istiersaa Oct Date AID 07f31119 PRN 1000 bjaa tegul.ra tnacdln aubcutanooLraty par Fes. Data slItEng scale: oath morning for 7 days "'PM 08/07/19 Ono— 09S9 NYM 122160- NYM Lnu:n Reg (00 M-)100 lINITS/ML Lnj -PlovideTsn-YJ = Documentation Codes: ORO = Order I NI = Dose Not Indcated Pt. Name: EPSTEIN, JEFFREY DOB: 0112043 Regdeabon St 76318-054 11:02 EST Report infornallon Is current as of the 4810 MCI tune of printing: 08/100019 EFTA00059450  76318-054 EPSTEIN. JEFFREY Medication Administration Record AUGUST 2019 Medication limo 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Ord. Dato IC/ 07(31119 PAN 1090 Ir*st tesailas hmu5n subcutaneously por Esp. On sCdIng scale: each moralni; for 7 days "'pw 01/07119 Cne"' 0959 MYM 172160. MYM Ustaat Reg (10 Ml..) 100 UNITSIMI. Provider:: YJ =M" Documentation Codes: ORD = Cider I NI r-. Dose Not Indicated Reg's-Batton P: 76318-054 Pt. Name: EPSTEIN. JEFFREY DOB: 01/20/53 Raport Inftxmalion is amtell es of the data and limo ot printing- 08/10/2019 11:02 EST EFTA00059451  Bureau of Prisons Health Services Devices and Equipment Start Date: 07/07/2019 Stop Date: owl012019 Reg #: 76315-054 Inmato Name: EPSTEIN, JEFFREY EDWARD Auks/Equipment Start Date Stop Dat0 Date Returned Obtained From Comments C-Pap 07/30/2019 14:05 EST MD 07/30/2019 Personal PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Total: 1 Page 1 of 1 Generated 0811012019 11:02 by RNAOPADC Bureau of Prisons - NYM EFTA00059452  Bureau of Prisons Health Services Pain Management Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD lagg intervention Pain Quality Location Ea Post Provider 07/12/2019 13:25 MEDROL DOSE PACK Shooting Back-Middle 5 MD Orig Entered: 07/1212019 13:28 EST MD Generated 09/102019 11:02 by RN/IOPADC Bureau of Prisons - NYM Page 1 of 1 EFTA00059453  Bureau of Prisons Health Services Modified Diet Re uest Types of Diets: Clear Liquid Exp Date: Low Fat Exp Date: Mechanical Soft Exp Date: Low Cholesterol Exp Date: Low Triglyceride Exp Date: Renal Exp Date: Full Liquid Exp Date: Sodium Controlled Exp Date: Snack Exp Date: Diabetic Exp Date: Calorie Controlled Exp Date: X Other. FISH ALLERGIES. Exp Date: 07/30/2020 Comments: Health Service Staff EPSTEIN, JEFFREY EDWARD 76318-054 07/30/2019 Inmate Name Reg# Date Generated 07/3012019 14:57 by MD Bureau of Prisons NYM Page 1 of 1 EFTA00059454  Bureau of Prisons Health Services Allergies Reg #: 78318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Allergy Pate Noted Reactlog No Known Allergies 07/06/2019 Orig Entered: 07/06/2019 21:40 EST Total: 1 Generated 08/10/2019 11:02 by Bureau of Prisons • NYM Page 1 of 1 EFTA00059455  Bureau of Prisons Health Services Patient Education Assessments & Topics Reg IS: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Assessments Assessment Learns Rest Ay primary I anguage Years of Education FiarfietSigntucatign Provider 07/09/2019 Speaking/Listening English 12 None 0rig Entered: 071091201912:52 EST M. Total: 1 Topics pate Initiated Format Handout/Toplq Outcome Provider 07/3012019 Counseling Access to Care Verbalizes Understanding Orig Entered: 07/30/2019 13:33 EST 07/30/2019 Counseling Plan of Care Verbalizes Understanding Orle Entered: 07/30/2019 13:34 EST 07/28/2019 Counseling Plan of Care Verbalizes Understanding Orig Entered: 07/28/2019 07:22 EST 07/28/2019 Counseling Plan of Care Verbalizes Understanding (prig Entered: 07/28/2019 20:30 EST 07/24/2019 Counseling Access to Care Verbalizes Understanding Orig Entered: 07/24/2019 13:23 EST ME. 07/24/2019 Counseling Preventive Health Verbalizes Understanding Ofig Entered: 07/24/2019 13:23 EST a 07/23/2019 Counseling Access to Care Verbalizes Understanding Orig Entered: 07/23/2019 09:04 EST -07123/2O1-9--- Counsaling Plan of -Care Verbalizes Understanding Orig Entered: 07/23/2019 09:04 EST 07/14/2019 Counseling . Diagnosis Verbalizes Understanding Orig Entered: 07/14/2019 18:11 EST 07/12/2019 Counseling Diagnosis Verbalizes Understanding Generated 08/10/2019 11:02 by RN/IOPI1DC Bureau of Prisons - NYM Page 1 of 2 EFTA00059456  Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Topics HandoutfTooic Outcome Provider Pate Initiated Format Ortg Entered: 07/12/2019 13:33 EST Total: 10 Page 2 oft Generated 08/1012019 11:02by RNnOWIDC Bureau of Prisons • NYM EFTA00059457  Bureau of Prisons Health Services Blood Glucose Begin Date: 07/07/2019 End Dato: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD (Reference Range: Random or Fasting 70 - 100, 2 hour post-prandial 70 - 140) DAR lama Yalua IY1211 Comments 08/04/2019 08:30 NYM 156 Non-Fasting Orig Entered: 08/04/2019 09:08 EST RN 08/02/2019 08:30 NYM 97 Non-Fasting Orig Entered: 08/0212019 08:16 EST =11 MLP 08/01/2019 06:30 NYM 103 Non-Fasting Orig Entered: 08/01/2019 09:00 EST MLP 07/31/2019 08:15 NYM 108 Non-Fasting Orig Entered: 07/31/2019 08:36 EST MEM MLP Total: 4 Generated 08/10/2019 11:02 by RN/IONDC Bureau of Prisons - NYM Page 1 of 1 EFTA00059458  Bureau of Prisons Health Services Health Problems Reg 01: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Axis Code I'm', Code Diagialia Status. Descnotion Current HyperilpIdemla, unspecified 07/12/2019 13:48 EST MD ICD-10 E785 07/12/2019 Current HYPERTRIGLYCERIDEMIA Sleep apnea MD ICD-10 G4730 07/12/2019 Current 07/12/2019 13:56 EST Essential (primary) hypertension MD ICD-10 110 07/30/2019 Current 07/30/2019 13:13 EST BY HX. Constipation, unspecified MLP ICD-10 K5900 07/09/2019 Current 07/09/2019 12:58 EST Low back pain MD ICD-10 M545 07/12/2019 Current 07/12/2019 13:30 EST Neuralgia and neuritis, unspecified MD ICD-10 M792 07/12/2019 Current 07/12/2019 13:30 EST No Diagnosis PhD/Chief I DSM-IV No Dx 07/09/2019 Current 07/09/2019 10:28 EST 1.1.1 syc o ogis Prediabetes MD ICD-10 R7303 07/30/2019 Current 07/30/2019 13:26 EST Injury, unspecified MLP ICD-10 T1490 07/23/2019 Current 07/23/2019 09:04 EST a RIO self inflicted injuries. Body mass Index (BMI) 27.0.27.9, adult MD ICD-10 Z6827 07/30/2019 Current 07/30/2019 13:14 EST Total: 10 Page 1 or 1 Generated 08/10201911:02 by RNIIOP/iOC Bureau of Prisons - NYM EFTA00059459  Bureau of Prisons Health Services Clinical Encounter Reg #: 76318.054 Inmate Name: EPSTEIN. JEFFREY EDWARD Sex: M Race: WHITE Facility: NYM Date of Birth: 01/20/1953 Provider: MD Unit: Z05 Encounter Date: 07/12/2019 13:10 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: MD 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 UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE Y HAS L4 - L5 SEVERE SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES. SURGICAL HX: NONE MENTAL HEALTH HX: 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 Ho: Appears Obese Genet/tied 07/12/2019 bk20 by Bureau of Prisons • NYM Page 1 of 3 EFTA00059460  Inmate Name: EPSTEIN. JEFFREY EDWARD Reg ft 76318.054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: Z05 Exam: Eyes General Yes: PERRLA, Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal Si 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 Neurologic 41) Cranial Nerves (CN) Yes: Systemn Withi Normal Limits Motor -General Yes: Normal Exam 0: 4 0,120 ASSESSMENT: Constipation, unspecified. K5900 - Current Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Sleep apnea, G4730 - Current 0el t PLAN: New Medication Orders: Bra Medication Order Date Prescriber Order Magnesium Hydroxide Susp 07/12/2019 13:10 30 CC Orally • Two Times a Day PRN x 2 day(s) Indication: Constipation, unspecified MethylPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 AS DIRECTED Orally - daily x Pack 21 tab) 6 day(s) Indication: Neuralgia and neuritis, unspecified Disposition: Generated 07/12/2019 14:20 by MD Bureau of Prisons • NYM Page 2 of 3 EFTA00059461 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM l Encounter Date: 07/12/2019 13:10 Provider: MD 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 Formal Handout/Topic Provider Outcome 07/12/2019 Counseling Diagnosis Verbalizes Understanding Copay Required:No Cosign Required: No TelephoneNerbal Order: Completed by n 07/12/2019 14:20 Generated 07/12/2019 14:20 by MD Bureau of Prisons NYM Page 3 of 3 EFTA00059462  Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Dale: 07/12/2019 13:10 Provider: MD Unit: Z05 Chronic Care -14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: MD 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 9, EIR GI SIDE EFFECTS. HX OF O iS)14ii LIVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. '•1 q? HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE Y HAS L4 - L5 SEVERE SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMI S. SURGICAL HX: NONE MENTAL HEALTH HX: 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 07/12/2019 14:20 by MD Bureau of Prisons • NYM Page 1 or 3 EFTA00059463  Inmate Name: EPSTEIN. JEFFREY EDWARD Reg )4: 76318-054 Date of Birth: 01)20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: Z05 Exam: Eyes General Yes: PERRLA, Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat d.Rhythm (RRR). Normal S1 and S2 No: M/R/G Abdomen Auscultation Yes: Normo-Active 8 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: EK.# Ke_dkation Order Date Prescriber Order Magnesium Hydroxide Susp 07/12/2019 13:10 30 CC Orally - T o Times a Day PRN x 2 day( ) Indication: Constipation, unspecified MethylPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 AS DIRECTED ly - daily x Pack 21 tab) 6 day(s) Indication: Neuralgia and neuritis, unspecified Disposition: Generated 07/12/2019 14'20 by MD Bureau of Prisons • NYM Page 2 of 3 EFTA00059464  Inmate Name: EPSTEIN, JEFFREY EDWARD Reg If: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD 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/Topic Pr_ovides, Outcome 07/12/2019 Counseling Diagnosis Verbalizes Understanding Copay Required: No .,---.) . Cosign Required: No i . TelephoneNerbal Order: Completed by D.,•n 07/12/2019 14:20 Generated 07/12/2019 14 20 by MO Bureau of Prisons • NYM Page 3 of 3 EFTA00059465  Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 71 8-054 Date of Birth: 01/20/1953 Sox: M Race: Encounter Date: 07/14/2019 17:36 Facility N Amendment mado to this note by MD on 07/14/2019 18:11. Bureau of Prrsons - NYM EFTA00059466  Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Reg /t: 76318-054 Date of Birth: 01/20/1953 Sex: Facility: NYM Note Date: 07/12/2019 09:08 Provider. MD Unit: ZO5 Admin Note - Orders encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider MD PATIENT REQUESTED TO HAVE A COLACE RX , INSTEAD OF TEH BISACODYL FOR CONSTIPATION. New Medication Orders: Rx# Medication Order Date prescriber Order Dccusate Sodium Capsule 07/12/2019 09:06 TAKE ONE 1r t MG CAP Orally - Two Times Day x 30 day(s) Indication: Constipation, unspecified Discontinued Medication Orders: adt Medication Order Date c ibe 121757-NYM Bisacodyl E.C. 5 MG TAB 07/1212019 09:06 Take one tatAit (5 MG) by mouth at bedtime AS NEEDED for 10 days Discontinue Type: When Pharmacy Processes Discontinue Roason:discontinue Indication: Copay Required: No Cosign Required: No TelephoneNerbal Order No Completed by MD on 07/12/2019 09:10 Generated 07/12/2019 09:10 by MD Bureau of Prisons - NYM Page 1 of 1 EFTA00059467  Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Facility: NYM Note Date: 07/07/2019 00:17 Provider- MD Unit: ECG Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider. MD MED CL:1 NO CCC APPT. Discontinued Laboratory Requests: Details Frequency Due Date Lab Tests-H-Hemoglobin AlC One Time 08/05/201900:00 R• Lab Tests-C-CBC w/diff Lab Tests-L-Lipld Profile Lab Tests-C-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Rellex to Microscopic Additional Information: 66 y/o male, elevated BP Labs requested to be reviewed by: MD New Laboratory Requests: DataHa Frequency Rue Date Priority Chronic Care Clinics-Diabetic-CBC w/diff One Time 07/25/2019 00:00 Routine Chronic Care Clinics-Diabetic-Lipid Profile Chronic Care Clinics-Diabetic-Hemoglobin A1C Lab Tests-H-HIV 1/2 Lab Tests-R-RPR Chronic Care Clinics-Diabetic-Comerehensive Metabolic Profile (CMP) New Radiology Request Orders: Details Frequency End aatft Due Pate Edo* General Radiology-Chest-2 Views One Time 07/25/2019 Ftouline Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH NO PMHX REFERRED FOR ROUITNE CXR. Copay Requlrod:No Cosign Required: No TelephoneNerbal Order: No Completed by MD on 07/07/2019 00:3