EFTA00105002.pdf

Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: Unit: HO Thorax: Contour Normal:Yes Increased AP Diameter: No Asymmetrical Expansion:No Lungs Clear: Yes Wheezes: No Crackles:No Rhonchl: No Rates: No Accessory Muscle Use: No Comments: Spine: Deformity: No Full ROM:Yes Tenderness:No Comments: Cardiovascular: RRR: Yes Normal S1/S2: Yos Murmurs: No Carotid Bruits:No JVD: No Arteries: Right Left Radial: Femoral: Dorsalis Pedis: Post. Tiblalls: Comments: Bureau of Prisons • NYM Page 10 of 13 Generated 07/09/2019 13:03 by EFTA00105002  Reg #: 7 18-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: Provider: Unit 1 Encounter Date: 07/09/201912:35 Abdomen: Normal Contour:Yes Scaphold: No Obese: No Gravid: No Hernias: No Bruits: No Masses:No Scars: No Tenderness: No Organomogaly: No Active Bowel Sounds: Yes Comments: Extremities: Nails Clubbing: No Nails Cyanosis: No Lower Extremity Edema - Right: None Lower Extremity Edema - Left: None Atrophy: No Amputations: No Other Deformities: No Varicosities:No Calf Tenderness: No Pulse Deficit: No Strength: Fight Sift Arm: Log: Full ROM: Right Arm: Yes Yee Leg: Yes Yes Comments: Etwoau of Prisons Pogo 11 of 13 Gene:rood 07/0912019 13:03 by EFTA00105003  Reg it: 78-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: Provider. Unit: Encounter Date: 07/09/2019 12:35 Reflexes: flight ken Biceps: Patellar: Brachioradialis: Achilles: Sensation: Vibratory: Yes Light Touch: Yes Pin Prick: Yes Comments: GU: Chaperoned By: Rectum: Not Done Comments: Refused. Male Genitalia: Not Done Comments: Refused. Skin: Normal:Yes Rash: No Redness:No Abnormal Pigmentation: No Abnormal Lesions/Growths: No Comments: Lymphatics: Adenopathy: No Comments: Potential Items For Follow-up: I1m Travel Outside US Other Infectious Disease History Rectum Not Done Male Genitalia Not Done PPD Administration Not Performed Comments: Patient has a history of constipation. Page 12 of 13 Generated 07/09/2010 13:03 by Bureau of Prisms - NYM EFTA00105004  Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: ITE Facility: NYM Date: 07/09/2019 12:35 Provider. Unit: H01 Encounter Cleared For Food Services: Yes Health Problems Newly Identified During This Encounter: Health Problem Constipation, unspecified - Current - Now Medication Orders: Palt Medication. Order Pate Bisacodyln. Tablet 07/09/2019 12:35 5 mg Ordy et bedtime PFtN x 10 day(s) Indication: Constipation, unspecified Disposition: Follow-up at Sick Call as Needed Instructed inmate how to obtain medical, dental, and mental health care. Copay Requlred:No Cosign Required: Yes TelophoneNerbal Order: No Completed by on 07/09/2019 13:03 Requested to be cosigned by Cosign documentation will be displayed on the following page. Generated 07/09/2019 13:03 by Bureau of Prisons • NYM P40134 13 EFTA00105005  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: Facility: N M 07/09/ 2019 12:35 Provid er: Encounter Date: Cosigned by on 07/11/2019 22:41. Burew W ftilscm - WM EFTA00105006  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 Bureau of Prisons - NYPA Page 1 of 2 Generated 08/10/2019 07:00 by EFTA00105007 Reg U: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD safeguard d. SENSITIVE BUT UNCLASSIFIED — This information Is confidential and must be appropriately 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 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 Namerfitle of Person Completing Form: Dal 08/10/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 DOB: 01/20/1953 Generated 08/10/2019 07:00 by Bureau of Prisons - NYM Page 2 or 2 EFTA00105008  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 lima Fahrenheit Celsius Location EIPMItiet 07/24/2019 13:12 NYM 97.8 36.6 Oral Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 NYM 97.5 36.4 Oral Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM 97.3 36.3 Oral Orig Entered: 07/09/2019 12:51 EST Pulse: Rate Per Minute I ()cation &Aim Provider Date It= 07/30/2019 13:02 94 Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:40 88 Via Machine Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:30 87 Vla Machine = Orly Entered: 07/30/2019 12:59 EST 07/28/2019 20:28 81 Orig Entered: 07/28/2019 20:29 EST 07/28/2019 06:57 82 Orig Entered: 07/28/2019 06:58 EST 07/24/2019 13:12 83 Via Machine Regular Ong Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 92 Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 82 Via Machine Via Machine Regular Regular MIMI IIIMI7. Orig Entered: 07M/2019 12:51 EST Respirations: Rata Time Rate Per Minute Provider 07/30/2019 09:30 NYM 12 Orly Entered: 07/30/2019 12:59 EST a 07/28/2019 20:28 NYM Orig Entered: 07/28/2019 20:29 EST a 07/28/2019 06:57 NYM Orly Entered: 07/28/2019 06:58 EST NMI 07/23/2019 06:30 NYM Oily Entered: 07/23/2019 08:33 EST MM . 07/09/2019 12:49 NYM Orig Entered: 07/09/2019 12:51 EST Bureau of Prisons - NYM Pogo 1 or 3 Generated O8V10/2019 11:02 by EFTA00105009 Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Blood Pressure: Value I °cation Position Cuff Size provider Oats Time 07/30/2019 13:02 NYM 114/84 Left Arm Standing Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:40 NYM 125/60 Right Ann Standing Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:30 NYM 108/86 Left Ann Sitting Orig Entered: 07/30/201912:59 EST 07/28/2019 20:28 NYM 157/91 Orig Entered: 07/28/2019 20:29 EST 07/28/2019 06:57 NYM 138/80 Orig Entered: 07/28/2019 06:58 EST ■ 07/24/2019 13:12 NYM 132/89 Right Arm Sitting Adult-regular MIS Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 NYM 140/85 Right Arm Sitting Adult-regular Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM 117/66 Right Arm Sitting Adult-regular Orig Entered: 07/09/2019 12:51 EST Blood Glucose: Date Time Value Imaldll Tyoe Regular Insulin provider 08/04/2019 08:30 156 Non-Fasting Orig Entered: 08/04/2019 09:08 EST 08022019 06:30 97 Non-Fasting Orig Entered: 08/02/2019 08:16 EST 08/01/2019 06:30 103 Non-Fasting Orig Entered: 08/01/2019 09:00 EST 07/31/2019 06:15 108 Non-Fasting Orig Entered: 07/31/2019 08:36 EST Sa02: Time Value/IA' Air Provider 07/30/2019 09:30 NYM 98 Room Air Orig Entered: 07/30/2019 12:59 EST 07/28/2019 20:28 NYM 98 Orig Entered: 07/28/2019 20:29 EST 07/28/2019 06:57 NYM 98 Orig Entered: 07/28/2019 06:58 EST 07/24/2019 13:12 NMI 96 Room Air Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 NYM 96 Room Air Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM 97 Room Air Orig Entered: 07/09/2019 12:51 EST Height Concealed Ob/10/2019 11:02 by Bureau of Prisons NYM Pepe 2 of 3 EFTA00105010 Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Data Emil Inches cm Provider 07/09/2019 12:49 NYM 70.0 * 177.8 Orig Entered: 07/09/201912:51 EST Weight: Data EMS Lin Kg Waist rtimuns Provider 07/30/2019 09:30 NYM 194.2 88.1 Orig Entered: 07/30/2019 12:59 EST 07/09/2019 12:49 NYM 194.4 88.2 Orig Entered: 07/09/2019 12:51 EST Generaled 08/10/2019 11:02 by Bureau of Prisons - NYM Pass Set 3 EFTA00105011  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 07/09/2019 12:47 0 mm Orig Entered: 07/06/2019 21:43 EST Odg Entered: 07/09/2019 12:47 EST Total: 1 Generated 08/10/2019 11:02 by lnOP/IDC Bureau of Prisons - NYM Page I 011 EFTA00105012  JULY 2019 76318-054 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 • 07/10/19 PRN 1421 Wort nqutc. Insulin stPcutrrtoousty per Exp. Dab acting 44,4J: Nrka (14'4 —•44:1 Ilnr for 7 07/31419 days 1001 NYM 122146- NYA4 tni.0 Rog (10 It.)100 UNITSR4I. Ceti. Date 07f31119 PFtN 1000 bjaa isgut& trautri Pubcutariernaly par Ey. Data OREN; scale: each morning /or 7 days "'PM 08/07/19 Ono— 09S9 WWI 122160- NYM Lnu:n Rog (10141—)10011NiTS/ML Lnj -Provide Occimereatien Codes: ORO = Order I NI = Dose Not InCficated Pt. Name: EPSTEIN, JEFFREY DOB: 0112049 Regsslrabon St 76318-054 08/100019 11:02 EST Report Inform lion Is current as of Uhl) 0480 MCI tune of printing: EFTA00105013 76318-054 EPSTEIN. JEFFREY Medication Administration Record AUGUST 2019 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 Orti Oslo 07/31119 PRN 1899 Ir*A regular Ins u5n subcutaneously per Exp. CRCs •Cdlag scale: 0OO ITINTI1219 for 7 days "'dm 0247119 0939 NYM 122160- ?NM tae-rh Reg (10 ML) 100 UNITSNL L' Providers Documentation Codes: ORD n Order I NI r: Dose Not Indicated RegStratton 0: 76318-054 Pt. Name: EPSTEIN. JEFFREY DOB: 01/20/53 Roped Infcanotion Is current as of the date and limo of printing- 08/10/2019 11:02 EST EFTA00105014  Bureau of Prisons Health Services Devices and Equipment Start Date: 07/07/2019 Stop Date: owl012019 Reg #: 76315-054 Inmato Name: EPSTEIN, JEFFREY EDWARD Peeks'Equipment Start Date Stop Date Pate Returned Obtained From Comments 1 -Pap 07/30/2019 14:05 EST 07/3012019 Personal PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Total: 1 Page 1 of 1 Generated 0811012019 11:02 by-SOP/1OC Bureau of Prisons - NYM EFTA00105015  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 gaig intervention Pain Quality Location Ea Post Provider 07/12/2019 13:25 MEDROL DOSE PACK Shooting Back-Middle 5 Orig Entered: 07/1212019 13:28 EST Generated O9/102019 11:02 by EVIONOC Bureau of Prisons - NYM Page 1 of 1 EFTA00105016  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 Bureau of Prisons - NYM Paget°, 1 EFTA00105017  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 EFTA00105018  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 Fistatersagittucatig0 Provider 07/09/2019 Speaking/Listening English 12 None 0rig Entered: 071091201912:52 EST MfM Total: 1 Topics pate Initiated Format Nandout/Toplq Outcome Provider 07/3012019 Counseling Access to Care Verbalizes Understanding Orig Entered: 07/30/2019 13:33 EST a 07/30/2019 Counseling Plan of Care Verbalizes Understanding Orig Entered: 07/30/2019 13:34 EST a 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 Ong Entered: 07/28/2019 20:30 EST a 07/24/2019 Counseling Access to Care Verbalizes Understanding Orig Entered: 07/24/2019 13:23 EST MI I 07/24/2019 Counseling Preventive Health Verbalizes Understanding Ong Entered: 07/24/2019 13:23 EST =I. I 07/23/2019 Counseling Access to Care Verbalizes Understanding Ong Entered: 07/23/2019 09:04 EST I. -07423/2O1S— Counseling Plan of Care Verbalizes Understanding Ong Entered: 07/23/2019 09:04 EST 07/14/2019 Counseling . Diagnosis Verbalizes Understanding Ong Entered: 07/14/2019 18:11 EST 07/12/2019 Counseling Diagnosis Verbalizes Understanding Generated 09110/201911:02by MAGID/IBC Bureau of Prisons - NYM Page 1 of 2 EFTA00105019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Topics Handoutifooic Outcome Provider Pate Initiated Format olio Entered: 07/12/2019 13:33 EST Total: 10 Page 2 e12 Generated 09/10!201911:02 by Bureau of Pitons -PPM EFTA00105020  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) Data lama Yalua Than Comments 08/04/2019 08:30 NYM 156 Non-Fasting Orig Entered: 08/04/2019 09:08 EST 08/02/2019 08:30 NYM 97 Non-Fasting Orig Entered: 08/02/2019 08:16 EST 08/01/2019 06:30 NYM 103 Non-Fasting Orig Entered: 08/01/2019 09:00 EST 07/31/2019 06:15 NYM 108 Non-Fasting Orig Entered: 07/31/2019 08:36 EST Total: 4 Generated 08/10/2019 11:02 by MilOPAIDC Bureau of Prisons - NYM Page 1 of 1 EFTA00105021  Bureau of Prisons Health Services Health Problems Reg 01: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Mt Code Tyon Code Diagialta Status. .Stalust2010. Descriotlon Current Hyperilpidemla, unspecified 07/12/2019 13:48 EST ICD-10 E785 07/12/2019 Current HYPERTRIGLYCERIDEMIA Sleep apnea ICD-10 64730 07/12/2019 Current 07/12/2019 13:56 EST Essential (primary) hypertension ICD-10 110 07/30/2019 Current 07/30/2019 13:13 EST BY HX. Constipation, unspecified ICD-10 K5900 07/09/2019 Current 07/09/2019 12:58 EST Low back pain ICD-10 M545 07/12/2019 Current 07/12/2019 13:30 EST Neuralgia and neuritis, unspecified ICD-10 M792 07/12/2019 Current 07/12/2019 13:30 EST No Diagnosis No Dx 07/09/2019 Current ME 07/09/2019 10:28 EST I DSM-IV Prediabetes ICD-10 R7303 07/30/2019 Current 07/30/201913:26 EST Injury, unspecified ICD-10 T1490 07/23/2019 Current 07/23/2019 09:04 EST R/O self inflicted injuries. Body mass Index (BM) 27.0-27.9, adult ICD-10 Z6827 07/30/2019 Current 07/30/2019 13:14 EST Total: 10 Pa;o 1 or 1 Generated 08/1O201911:02by EACH= Bureau of Prisons - NYM EFTA00105022  Bureau of Prisons Health Services Clinical Encounter Reg Sr: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Sex: M Race: WHITE Facility: NYM Date of Binh: 01/20/1953 Provider: Unit: Z05 Encounter Date: 07/12/2019 13:10 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 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 -1.5 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 Not Appears Obese Generated 07/12/2019 14,20 by Bureau of Prisons • NYM Page I of 3 EFTA00105023  Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: 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 Bureau of Prisons • NYM Page 2 of 3 EFTA00105024 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM I Encounter Date: 07/12/2019 13:10 Provider: 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 Bureau of Prisons NYM Page 3 of 3 EFTA00105025  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 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 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 Bureau of Prisons • NYM Page 1 or 3 EFTA00105026  Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01)20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider 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 1420 by Bureau of Prisons • NYM Page 2 of 3 EFTA00105027  Inmate Name: EPSTEIN, JEFFREY EDWARD Reg It: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: 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/Toeic Pr_oytdel Outcome 07/12/2019 Counseling Diagnosis Verbalizes Understanding Copay Required: No i Cosign Required: No TelephoneNerbal Order: Completed by 07/12/2019 14:20 el, Generated 07/ 12/2019 14:20 by Bureau of Prisons • NYM Page 3 of 3 EFTA00105028  Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 71 8-054 Date of Birth: 01/20/1953 Sox: A4 Race: Encounter Date: 07/14/2019 17:36 Facility N Amendment mado to this note by on 07/14/2019 18:11. Bureau of Prrsons - NYM EFTA00105029  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. Unit: ZO5 Admin Note - Orders encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider PATIENT REQUESTED TO HAVE A COLACE FtX INSTEAD OF TEH BISACODYL FOR CONSTIPATION. New Medication Orders: Rx# Medication Order Date prescriber Order Dccusate Sodium Capsule 07/12/2019 09:C6 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.. 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 on 07/12/2019 09:10 Generated 07/12/2019 09:10 by Bureau of Prisons - NYM Page 1 of 1 EFTA00105030