EFTA00140183.pdf

Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg il: 76318.054 Date of Binh: 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: 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 EXTREM 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: MD 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 Genorteed 07/7212019 74:20 by-MD Bureau of Prisons NYM Page I of 3 EFTA00140183 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/12/2019 13:10 Reg #: 76318-054 Sex: E Facility: NYM Provider: MD Unit: Z05 0S Eyes General Yes: PERRLA, Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal S1 and S2 No: M/R/G Abdomen Auscultation Yes: Normo-Active B Palpation Yes: Within Normal Limits Musculoskoletal Tibia / Fibula No: Edema Back Yes: Tenderness ithin Neurologic Cranial Nerves (CN) Yes: W ASSESSMENT: Constipation, unspecified. K5900 - Current Motor System-General Normal Limits Yes: Normal Exam Neuralgia and neuritis. unspecified. M792 - Current Low back pain, M545 - Current 4 >dor Hyperlipidemia. unspecified. E785 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: RX# MedkaitieO Order Date Magnesium Hydroxide Susp 07/12/2019 13:10 Indication: Constipation, unspecified MethylPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 Pack 21 tab) Indication: Neuralgia and neuritis, unspecified Disposition: Prescriber Order 30 CC Orally - Two Times a Day PRN x 2 day(s) AS DIRECTED Orally - daily x 6 day(s) Generated 07/12/2019 14:20 by MD Bureau of Prisons - NYM Page 2 of 3 EFTA00140184 Inmate Name: EPSTEIN, JEFFREY EDWARD Dale of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/12/2019 13:10 Provider: SD Reg U: 76318-054 Facility: NYM Unit: 205 Follow-up at Sick Call as Needed Other: WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP. Patient Education Topics: Date Initiated Format kla ndodtartnic. 07/12/2019 Counseling Diagnosis Copay Required: No Cosign Required: No TelephoneNerbal Order: Completed b 07/12/2019 14:20 Provider Outcome Verbalizes Understanding Generated 07/12/2019 14.20 by MD Bureau of Prisons - NYM Page 3 of 3 EFTA00140185 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 1$: 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: 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 ,744: 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 EXTREMI S SURGICAL HX: NONE MENTAL HEALTH HX: Pain: Yes Pain Assessment Dato: 07/12/2019 13:25 Location: Back-Middle Quality of Pain: Shooting Pain Scale: 5 Intervention: MEDROL DOSE PACK Trauma DateNear: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: MD 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 of EFTA00140186 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/12/2019 13:10 Reg tl: 76318-054 Sex: TE Facility: NYM Provider: I 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 S1 and S2 No: M/R/G Abdomen Auscultation Yes: Normo-Active B Palpation Yes: Within Normal Limits Musculoskcletal 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: Rx# Medication aOr Date Magnesium Hydroxide Susp 07/12/2019 13:10 Indication: Constipation, unspecified MethylPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 Pack 21 tab) Indication: Neuralgia and neuritis, unspecified Disposition: Prescriber Order 30 CC Orally - Two Times a Day PRN x 2 day(s) AS DIRECTED Orally - daily x 6 day(s) Ceeeraleal Ot 12/2019 14 20 by MD Bureau of Prisons NYM Page 2 of 3 EFTA00140187 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/121201913:10 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: Pate Initiated Format Handout/Topic 07112r2019 Counseling Diagnosis Copay Required:No Cosign Required: No TelephoneNerbal Order: Completed by i07/12/2019 14:20 Provider !Dirtc_42me. Verbalizes Understanding Generaied 07/12/2019 14:20 by MD Bureau of Prisons - NYM Page 3 of 3 EFTA00140188 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/14/2019 17:36 Facility: NYM Amendment made to this note by MD on 07/14/2019 18:11. Bureau of Prisons - NYM EFTA00140189 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: Date of Birth: Note Date: EPSTEIN, JEFFREY EDWARD 01/20/1953 Sex: 07/12/2019 09:06 M_SicajoadaL Provider: MD Reg #: Facility: Unit: 76318-054 NYM 205 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: thst Medication Docusate Sodium Capsule Indication: Constipation, unspecified Discontinued Medication Orders: Medication 121757-NYM Bisacodyl E.C. 5 MG TAB Order Date 07/12/2019 09:06 Order Date 07/12/2019 09:06 Discontinue Type: When Pharmacy Processes Discontinue Reason:discontinue Indication: Copay Required:No TelephoneNerbal Order No Completed by Generated 07/12/2019 09:10 by Cosign Required: No MD on 07/12/2019 09:10 MD Bureau or Prisons - NYM Prescriber Order TAKE ONE 100 MG CAP Orally - Two Times a Day x 30 day(s) prescriber Order Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10 days Page 1 of 1 EFTA00140190 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg ff: 76318-054 Date of Birth: 01/20/1953 Sex: Facility: NYM Note Date: 07/07/2019 00:17 Provider: MD Unit: E06 Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MED CL:1 NO CCC APPT. MD Discontinued Laboratory Requests: Retail' Frequency Due Date Priority Lab Tests-H-Hemoglobin A1C One Time 08/05/2019 00:00 Routine Lab Tests-C-CBC w/diff Lab Tests-L-Lipid Profile Lab Tests-C-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic Additional Information: 66 y/o male, elevated 8P Labs requested to be reviewed by: MD New Laboratory Requests: Details Freouencv Due 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-Comprehensive Metabolic Profile (CMP) New Radiology Request Orders: Details Frequency End Date Due Date Pri ority General Radiology-Chest-2 Views One Time 07/25/2019 Routine Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR. Copay Required: No TelephoneNerbal Order: No Completed by Generated 071072019 00:30 by Cosign Required: No MD on 07/07/2019 00:30 MD Bureau of Prisons • NYM Page 1 of 1 EFTA00140191 Bureau of Prisons Health Services History & Physical Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/09/2019 12:35 Provider: . MLP Reg #: 76318-054 Facility: NYM Unit: H01 Seizures: Denied Diabetes: Denied Cardiovascular: Denied CVA: Denied Hypertension: Denied Respiratory: Denied Sickle Cell Anemia: Denied Carcinoma/Lymphoma: Denied Allergies: Denied Tuberculosis: Hx of Previous Disease: No Blood-tinged Sputum: No Night Sweats: No Weight Loss: No Fever: No Cough:No Comments: Infectious Disease Risk Factors: IV Drug Use: No IV Drug Use Needles: Sexual Partner IV Drug Use: No Sexual Partner IV Drug Use Needles: Female Sexual Partners (Last 5 Yrs): 10+ Male Sexual Partners (Last S Yrs): 0 Condom Use: Sometimes Sexual Contact With HIV+ Individual: No Blood Product Transfusion: No Travel Outside US: Yes Tattoos: No Comments: Born in US High school diploma Banker Traveled to Paris x 3 weeks up until arrest No tattoos Generated 07/09/2019 13 03 by MLP Bureau of Prisons NYM Page 1 of 13 EFTA00140192 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date 07/09/2019 12:35 Provider: . MLP Unit: H01 HIV History: When Tested: 2019 Test Result: Negative When Diagnosed AIDS: Last CD4: Comments: Hepatitis: Denied Other Infectious Diseases: Syphilis: No Syphilis Last Treatment: N/A Genital Warts: No Chlamydia: Yes Gonorrhea: No Herpes: No Chicken Pox: Yes Other: No Comments: Chlamydia in 2015, treated Chicken pox In childhood Abuse History: Denied Physical: No Emotional: No Sexual: No Comments: Denies Generated 07/09/2019 13.03 by b1LP Bureau of Prisons - NYM Page 2 of 13 EFTA00140193 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: e: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: . MLP Unit: H01 Mental Health: Level of Consciousness: Alert and Oriented Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Hx of Mental Health Treatment: None Hx of Head Injury: None Current Mental Health Treatment: No Current Mental Health Complaint: No Hx of Loss of Consciousness: No Hx of Hearing Voices: No Past History of Suicide Attempt: No Current Suicide Ideation: No Suicide Prevention Initiated:No Comments: Substance Use History: Denied Current Painful Condition: Denied Other Health Issues: Current Medical Conditions: Other Current Treatments: Pregnant: N/A Dental Condition: Denied Generated 01/09/2019 13.03 by MLP Bureau of Prisons - NYM Page 3 of 13 EFTA00140194 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: i m aie: WHITE Facility: NYM co En unter Date: 07/09/2019 12:35 Provider: MLP Unit: H01 Observations: Draining Skin Lesions: No Signs of Lice: No Signs of Scabies: No Signs of Recent Trauma: No Recent Tattoos: No Needle Marks: No Signs of Rash: No Open Sores: No Wounds: No Body Deformities: No Tremors: No Sweating: No Comments: Generated 07/09/20W t3:03 by MIR Bureau of Prisons - NYM Page 4 of 13 EFTA00140195 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: H01 Immunizations: Hepatitis A and B (TwinRx) Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Measles/Mumps/Rubella Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: . MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Smallpox Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Tetanus Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Generaled 07/09/2019 13O3 by MLP Bureau of Prisons • NYM Page 5 of 13 EFTA00140196 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/09/2019 12:35 Provider: MLP Reg #: 76318-054 Facility: NYM Unit: H01 Immunization Date: Provider: ME MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Varicella Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider. MEM MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Temperature: Data lima Fahrenheit Celsius Location provider 07/09/2019 12:49 NYM 97.3 36.3 Oral MLP Pulse: Data Time Rate Per Minute Lactation Rhythm provider 07/09/2019 12:49 82 Via Machine Regular MLP Respirations: Data Rate Per Minute Provider 07/09/2019 12:49 NYM 16 MLP Blood Pressure: Data Time Value location Pathan Cuff Size Provider 07/09/2019 12:49 NYM 117/66 Right Arm Sitting Adult-regular s MLP SaO2: Data Time Value(%) Air Provider 07/09/2019 12:49 NYM 97 Room Air MLP Height: Date /line Inches rim provider 07/09/2019 12:49 NYM 70.0 177.8 MLP Generated 07/09/201913:03 by Bureau of Prison-NYM Page 6 of 13 EFTA00140197 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: H01 Dail Time lard= gat Provider Weight: Pate Time Lag Kg Waist Circum, Provider 07/09/2019 12:49 NYM 194.4 88.2 MLP Prosthetic Devices/Equipment: Denied Tobacco Usage: Denied General Social History: Foreign Travel: Born in USA: Yes Country of Birth: USA Patient Education Assessments: Date Ed Yrs Occupation Learns Best By Primary Language Barriers to Education 07/09/2019 12 Banker Speaking/Listening English None Family History - Father. Age at Death: 74 Cause of Death: Diabetes complications Significant Illnesses: Diabetes Heart Disease Comments: Family History - Mother: Age at Death: 81 Cause of Death: Kidney Failure Significant Illnesses: Heart Disease Comments: Family History - Sibling: Number of Siblings: 1 Significant Illnesses: Comments: Past Hospitalization: Reason Acute Appendicitis Complications: None Comments: Head: Normal: Yes Comments: Location Mount Sinai Hospital When 1990 Generated 07/09/2019 13.03 by Bureau of Pascoe - NYM Page 7 of 13 EFTA00140198 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: H01 Eyes: EOMI: Yes lcterus:No Conjunctival Inflammation: No Pupils PERRLA: Yes Pupil Size Rt: Pupil Size Lt: Pupils Comments: Fundi Vessels Nicking: No Fundi Vessels Discs Flat:Yes Fundi Vessels Discs Sharp Margins: Yes Fundi Vessels Grounds Abnormal: No Eyes Comments: Vision Screen 07/09/2019 12:52 Blindness: With Corrective Distance Vision: OD: 100 OS: 70 OU: OD: OS OU: Near Vision: OD: OS: OU: OD: OS: OU: ishihara Color Test: Tonometry: L: R: Comments: Needs evaluation with optometrist. Ears: Right Ear: Canal patent Left Ear. Canal patent Ears Comments: Nose: Nares Patent: Yes Septum Midline:Yes Septum Intact: Yes Drainage/Discharge: No Polyps: No Nose Comments: Generals 07/09/2019 13.03 by MEI. SIP Bureau ot Prisons - NYM Page 9ol 13 EFTA00140199 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: R : WHITE Facility: NYM Encounter Date: 07/09/201912:35 Provider: MLP Unit: H01 Mouth Leslons:No Oral/Buccal Mucosa:Yes Gums Normal: Yes Tonsils Present: Yes Tonsils Normal: Yes Pharynx: Normal Color Teeth Poor Dentition: No Teeth Count:Mostly Present Dentures: No Mouth Comments: Cranial Nerves: Intact II•XII: Yes Cranial Nerves Comments: Neck: Full ROM:Yes Masses/Nodes: No Trachea: Midline Thyroid: Normal Size Comments: Breasts: Normal: Yes Masses:No Tenderness:No Scars: No Dimpling:No Nipple Discharge: No Nipple Retraction: No Instructions for Self Breast Exam Given: No Comments: Generated 07109/2019 13:03 by MLP Bureau of Prisons • NYM Page 90 13 EFTA00140200