DOJ-OGR-00024120.jpg
Extracted Text (OCR)
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: MD Unit: Z05
Chronic Care - 14 Day Physician Eval encounter performed at Health Services.
SUBJECTIVE:
COMPLAINT 1 Provider: ee
Chief Complaint: ENDO/LIPID
Subjective: 66 YRO HITE MALE WITH HX OF
HYPER CERIDEMIA xX 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS
800 , » STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE
MED EIR GI SIDE EFFECTS.
HX OF UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP
MACHINE. HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED.
STATES TH Y HAS
L4 - L5 SEVERE
LOWER EXTREMITMES.
SURGICAL HX: NONE
MENTAL HEALTH Hx:
SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE
Pain: Yes
Pain Assessment
Date: 07/12/2019 13:25
Location: Back-Middle
Quality of Pain: Shooting Q
Pain Scale: 5
Intervention: MEDROL DOSE PACK
Trauma Date/Year: Y
Injury:
Mechanism:
Onset: 5+ Years
Duration: 5+ Years Q
Exacerbating Factors: NO EXERCISE
Relieving Factors: MEDROL DOSE PACK lal
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 Ill
Nutrition
No: Appears Obese
Generated 07/12/2019 14:20 byfON6), OYE) MD Bureau of Prisons - NYM Page 1 of 3
DOJ-OGR-00024120
Extracted Information
Document Details
| Filename | DOJ-OGR-00024120.jpg |
| File Size | 599.7 KB |
| OCR Confidence | 91.5% |
| Has Readable Text | Yes |
| Text Length | 1,647 characters |
| Indexed | 2026-02-03 20:44:37.894801 |