EFTA00134682.pdf

Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 4: 76, 18-054 Date of Birth: 01/20/1953 Sex: Race: WHITE Facility: 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 Tondornoss:No Comments: Cardiovascular: RRR: Yes Normal S1/S2: Yos Murmurs: No Carotid Bruits:No JVD: No Arteries: Right Left Radial: Femoral: Dorsalis Podis: Post. TIblalls: Comments: Generated 07/09/2019 13:03 by Bureau of Prisons • NYM Page 10 of 13 SDNY_C0003938 EFTA_00000 147 EFTA00134682  Reg #: 7 18454 Inmate Name: EPSTEIN, JEFFREY EDWARD 01/20/1953 Sex: M Race: WHITE Facility: Date of Birth: Unit 1 Encounter Date: 07/09/2019 12:35 Provider: Abdomen: Normal Contour:Yes Scaphoid: 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: Plight Soft Arm: Log: Full ROM: Right LA Arm: Yes Yes Leg: Yes Yes Comments: Buntou of Prisons Page 11 of 13 Generated 07109/2019 13:03 by SbNY_00000939 EFTA_00000148 EFTA00134683  Reg ft 78-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: Provider. Unit: 1 Encounter Date: 07/09/2019 12:35 Reflexes: Bight knit 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 LosIons/Growths: No Comments: Lymphatics: Adenopathy: No Comments: Potential Items For Follow-up: ISM 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. Psg. 12 of 13 Generated 07/09/2019 13:03 by Bureau of Prisms - NY M DNY_00000940 EFTA_00000149 EFTA00134684  Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: itHITE Facility: NYM Provider. Unit: H01 Date: 07/09/2019 12:35 Cleared For Food Services: Yes Health Problems Newly Identified During This Encounter: Health Problem Constipation, unspecified - Current - Now Medication Orders: Medication Order Date halAdbladli Bisacodyl E.C. Tablet 07/09/2019 12:35 5 mg Only at bedtime PFtN x10 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 Required:No Cosign Required: Yes TelephoneNerbal 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 Paps 13 of 13 SONY- 00000941 EFTA_000001 50 EFTA00134685  Bureau of Prisons Health Services Cosign/Review Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD WHITE Sex: M Race: Date of Birth: 01/20/1953 12:35 Provider: Facility: NYM Encounter Date: 07/09/2019 Cosigned by on 07/11/2019 22:41. Bureau of Prisons - NYM SDNY_00000942 EFFA_00000 1 5 1 EFTA00134686  Bureau of Prisons Health Services Inmate Local Hospital Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD safeguarded. SENSITIVE BUT UNCLASSIFIED — This information Is confidential and must be appropriately Transfer To: Transfer Date: 08/10/2019 Health Problems Health Problem ate= Hyperripldemia, 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 icated. 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 SIG: Take one capsule (100 MG) twice daily by th with plenty Docusate Sodium 100 MG Cap Exp: 01/22/2020 of water 10ml by th twice Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML Exp: 10/28/2019 SIG: shake well take daily AS NEEDED uth with food Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by OTCs: Listing of all known OTCs this inmate is currently taking. None Pending Appointments Time Activity Provider Date 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 Freouency Duration Petah 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 I Re 1el 2 Generated 08/10/2019 07:00 by S NY 00000903 EIFIA_00000152 EFTA00134687 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 Dat 08/10/12019 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 DOB: 01/20/1953 Generated 08/10/2019 07:00 by RN Bureau olPrisons- NYM ONIVieroV94? EFTA_00000 1 53 EFTA00134688  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 Celsius Location EOM& 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 Rhythm Provider Data _VMS 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 Via Machine Orly Entered: 07/30/2019 12:59 EST 07/28/2019 20:28 81 Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 82 Orly Entered: 07/28/2019 06:58 EST RN 07/24/2019 13:12 83 Via Machine Regular Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 92 Via Machine Regular Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 82 Via Machine Regular Orig Entered: 07/09/2019 12:51 EST Respirations: Rate. Inn Rate Per Minute. Provider 07/30/2019 09:30 NYM 12 Orly Entered: 07/30/2019 12:59 EST 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 16 Orly Entered: 07/23/2019 08:33 EST 91116 07/09/2019 12:49 NYM Orig Entered: 07/09/2019 12:51 EST Bureau of Prisons - NYM Pogo 1of 3 Generated 0&10/2019 11:02 by ONY_00000945 EFTA_00000 1 54 EFTA00134689  End Dato: 08/10/2019 Begin Date: 07/07/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Blood Pressure: Position Cuff Sin Provider Pate. Time Value Location 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 Loft Arm Sitting Orig Entered: 07/30/2019 12:59 EST 07/28/2019 20:28 NYM 157/91 Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 NYM 138/80 Orig Entered: 07/28/2019 06:58 EST RN 07/24/2019 13:12 NYM 132/89 Right Arm Sitting Adult-regular 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 km Sitting Adult-regular Milat Orig Entered: 07/09/2019 12:51 EST Blood Glucose: Time Value fmg/dll Type Regular Insulin Provider Date 08/04/2019 08:30 156 Non-Fasting Orig Entered: 08/04/2019 09:08 EST Re 08/02/2019 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: Date Time Valuef%1 Alt 07/30/2019 09:30 NYM 98 Room Air Orig 07/28/2019 Orig 07/28/2019 Bureau of Prisons NYM Page 2 of 3 Generated 08/10/2019 11:02 by ONY_00000946 EFTA_00000155 EFTA00134690 Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date Emil Inches CIO Provider 07/09/2019 12:49 NYM 70.0 * 177.8 Orig Entered: 07109/201912:51 EST Weight: Datet Time Lits Kg Minn 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 Bureau of Prisons - NYM Page 3 al 3 Generated 08/10/2019 11:02 I S.0NY_00000947 EFFA_00000 1 56 EFTA00134691  Bureau of Prisons Health Services PPDs Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Adrnin: 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 RNAOPADC Bureau of Prisons - NYM SDNY_000C0P et I °I l EFTA 00000157 EFTA00134692  JULY 2019 76318454 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 ob. Dim • e 07/1009 PRN 1421 tr0ecl neck: Insulin reScuttrieousty per Exp. Dee) acting 544(J: niece Cary —pUJ Heir' for 7 07/31/19 days 1001 NW 122148- NM/ frepta, Reg (10 IA-) 100 UNITSR4L tri Ccd. Date 0701/19 PRN 1000 Nect mauls Inaulth tigotaneously par Ev. Data sllepig scale: each In for 7 days ^pi0 08/07/19 Ono 0959 WM 122160- NYM hau:n Reg (10 AC) 100 UNITS/ML etj -PlovirletTYJ = JoaquIn:Y. Ocannonatian Codes: ORO = Order I NI = Dose Not Iodated Pt. Name: EPSTEIN. JEFFREY DOB: 01120/63 Registration 0- 76318-054 11:02 EST Report lnforma0on Is current as of lhe 0/1(0 end lane of printing: 08/100019 EFTA00134693  76318-054 EPSTEIN. JEFFREY AUGUST 2019 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 04. Dan Bornidote-i. Robert VD 07/31119 PIN 1899 Ir*rt So' Ins win subcutanooesty per Exp. On MOlag scale: oath rooming for 7 days "VII 0247119 too"' 0959 NYM 122160- ?NM IrouLot Rog (10 ML) 100 UNITSUL 04; - Providers: YJ = JoarniarCiT Documentation Codes: ORO = Order I NI = Doso Not Indicated Registration 0: 76318-054 Pt. Name: EPSTEIN. JEFFREY DOB: 01/20/53 Report Infoana*n Is current as of the date and limo of printing 08/1072019 11:02 EST EFTA00134694  Bureau of Prisons Health Services Devices and Equipment Start Date: 07/07/2019 Stop Date: owl012019 Reg #: 76315-054 Inmato Name: EPSTEIN, JEFFREY EDWARD Peaks/Equipment Start Pate Stop Date Pate Returned Obtained From Comments C-Pap 07/30/2019 14:05 EST 07/3012019 Personal PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL. #: P1131281381ED. Total: 1 Bureau of Prisons - NYM Page t of Generated M1012019 11:02 by RNAOPP0C SDNY_00000951 EFTA_00000160 EFTA00134695  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 =it Intervention, Pain Quality Ls/crating Pig Post Provider 07/12./2019 13:25 MEDROL DOSE PACK Shooting Back-Middle 5 Orig Entered: 07/12/2019 13:28 EST Generated 08/10/2019 11:02 by RN/1OPADC Bureau of Prisons - NYM soiftrag21 EFTA 00000161 EFTA00134696  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 Page loll ONY_00000953 EFTA_00000 1 62 EFTA00134697  Bureau of Prisons Health Services Allergies Reg #: 78318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Allergy Pate Noted Reaction 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 SON`;,aTotolL EFTA_00000 163 EFTA00134698  Bureau of Prisons Health Services Patient Education Assessments & Topics Reg IS: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Assessments Assessment Learns Rest By Primary I language Years of Education ers To Education Provider 07/09/2019 Speaking/Listening English 12 None 0rig Entered: 071091201912:52 EST Total: 1 Topics Pate Initiated Format Handout/Topic Outcome Provider 07/30/2019 Counseling Access to Care Verbalizes Understanding Ong Entered: 07/30/2019 13:33 EST 07/30/2019 Counseling Plan of Care Verbalizes Understanding Orig Entered: 07/30/2019 13:34 EST 07/28/2019 Counseling Plan of Care Verbalizes Understanding Odg Entered: 07/28/2019 07:22 EST 07/28/2019 Counseling Plan of Care Verbalizes Understanding Orig Entered: 07/28/2019 20:30 EST 07/24/2019 Counseling Access to Care Verbalizes Understanding Orig Entered: 07/24/2019 13:23 EST 07/24/2019 Counseling Preventive Health Verbalizes Understanding Ong Entered: 07/24/2019 13:23 EST 07/23/2019 Counseling Access to Care Verbalizes Understanding Orig Entered: 07/23/2019 09:04 EST -07123/204-9— Counseling Plan oftare 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 08/1012019 11:02 by RMOPADC Bureau of Prisons - NYM t of 2 sot4c000cosPr EFrA_00000164 EFTA00134699  Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Topics Hand Outcome Provider Pate Initiated Format Orig Entered: 07/12/2019 13:33 ES Total: 10 L11 Page 2012 Gemmedoinomolidaliares.Terrance RNnOWIDC Bureau of Prisons • NYM EFTA00134700  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 IY121 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: 08/02/2019 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 08/1012019 11:02 by RN/IOPAIDC Bureau of Prisons - NYM Page 104 1 SDNY_00000957 EFTA_00000166 EFTA00134701  Bureau of Prisons Health Services Health Problems Reg 01: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Axle Code Type Code Ding Date Status. Descnotion Current Hypertipidemla, unspecified 07/12/2019 13:48 EST ICD-10 E785 07/12/2019 Current HYPERTRIGLYCERIDEMIA Sleep apnea ICD-10 G4730 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 .1 03 I DSM-IV No Dx 07/09/2019 Current 07/09/2019 10:28 EST IL is Prediabetes ICD-10 R7303 07/30/2019 Current 07/30/2019 13:26 EST Injury, unspecified ICD-10 T1490 07/23/2019 Current 07/23/2019 09:04 EST R/O self inflicted injuries. Body mass Index (BMI) 27.0-27.9, adult ICD-10 Z6827 07/30/2019 Current 07/30/2019 13:14 EST Total: 10 Generated 08/1O201911:02 by Ral/tOPADC Bureau of Prisons - NYM PZ SDNY_00CO0 1 EFTA 00000167 EFTA00134702  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: Unit: 205 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 O1_ 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 No: Appears Obese Generated 07/12/2019 Iik20 by Bureau of Prisons • NYM Page 1 of 3 SDNY_00000959 EFTA_00000 1 68 EFTA00134703  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: 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 ASSESSMENT: Constipation, unspecified. K5900 - Current Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Sleep apnea, G4730 - Current 40>e 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 SDNCISClig 3 EFTA_00000 1 69 EFTA00134704 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: 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 , Robert Verbalizes Understanding Copay Required:No F, Cosign Required: No TelephoneNerbal Order: Completed by , RQbetMi..n 07/12/2019 14:20 Generated 07/12/2019 14:20 by Bureau of Prisons NYM Page 3 of 3 SDNY_00000961 EFTA_00000 1 70 EFTA00134705  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 3DNY_00000962 EFTA_00000171 EFTA00134706 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: 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-ActiveB Palpation Yes: Within Normal Limits MUSCUloskeletal Tibia / Fibula No: Edema Back Yes: Tenderness Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System