EFTA00033825.pdf

Type: pdf
Source set: data-set-8
Extracted text

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: 
07/12/2019 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, 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: Cle…
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