EFTA00033811¶
| Inmate Name: Date of Birth: | EPSTEIN, JEFFREY EDWARD 01/20/1953 | Sex: | Reg #: Facility: | 76318.054 NYM | |
|---|---|---|---|---|---|
| Note Date: | 07/24/2019 16:10 | Provider: | MD | Unit: | H01 |
| Administrative Notes: | Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. | ||||
| ADMINISTRATIVE NOTE 1 | Provider: | MD | |||
| THE | NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. | ||||
| Copay Required:No | v | Cosign Required: No | |||
| TelephoneNerbal Order: | No | ||||
| Completed by Beaudouin. Robe | 24/2019 16:12 | ||||
CONFIDENTIAL SDNY_00009406¶
| Inmate Name: Date of Birth: Note Date: | EPSTEIN, JEFFREY EDWARD 01/20/1953 07/24/2019 16:10 | Sex: Provider: | N .M. | MD | Reg #: Facility: Unit: | 76318-054 NYM H01 |
|---|---|---|---|---|---|---|
| Administrative Notes: | Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. | |||||
| ADMINISTRATIVE NOTE 1 | Provider: | MD | ||||
| THE IM NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. | ||||||
| Copay Required:No | Cosign Required: No | |||||
| TelephoneNerbal Order: | No | |||||
| 6124/2019 16:12 Completed by Beaudouin, Robe |
MD Bureau of Prisons • NYM Pagel°, 1¶
CONFIDENTIAL SONY 00009407¶
Bureau of Prisons Health Services See Amendment¶
| Inmate Name: Date of Birth: | EPSTEIN, JEFFREY EDWARD 01/20/1953 Encounter Date: 07/26/2019 08:57 | Sex: | M | Reg #: Race: Facility: | 76318-054 WHITE NYM | |
|---|---|---|---|---|---|---|
| Amendment made to this note by | MD on 07/26/2019 08:58. |
SUMO or Prisons - NYM¶
| Inmate Name: | EPSTEIN, JEFFREY EDWARD | Reg #: | 76318-054 | |||||
|---|---|---|---|---|---|---|---|---|
| Date of Birth: Note Date: | 01/20/1953 07/24/2019 15:10 | Provider: | 1 m | M. | fro | Facility: Unit: | NYM H01 |
Admin Note - General Administrative Note encounter performed at Health Services. Administrative Notes:¶
ADMINISTRATIVE NOTE 1 Provider: MD¶
PATIENT WAS OFFERED TO HAVE AN OPTOMETRIST EVALUATION. HE REFUSED. REFUSAL FORM SIGNED.¶
Copay Required: No¶
Cosign Required: No¶
TelephoneNerbal Order: No¶
Completed by MD on 07/24/2019 15:17¶
Generated 07/24201915:17 by¶
| Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: M Race: WHITE Facility: NYM 01/20/1953 Sex: Encounter Date: 07/24/2019 13:08 Provider: Unit: H01 |
|---|
| Mid Level Provider - Follow up Visit encounter performed at Receiving & Discharge. |
| SUBJECTIVE: |
| Provider: COMPLAINT 1 Chief Complaint: Other Problem Subjective: I still do not want to talk about. But, between you and me. I think my room mate had to do with what happened to me. Do not ask me. I am not going to say anything. Pain: No |
| OBJECTIVE: Temperature: |
| Provider Fahrenheit Celsius Location Data Time |
| 13:12 NYM 97.8 36.6 Oral 07/24/2019 |
| Pulse: |
| Location Provider Daft Rate Per Minute Lima Rhythm |
| Regular 07/24/2019 13:12 83 Via Machine |
| Blood Pressure: |
| Position Provider Location Cuff Size Time Value Date 07/24/2019 13:12 NYM 132/89 Right Arm Sitting Adult-regular |
| SaO2: |
| Valuer%1 Air Provider Date Time 13:12 NYM 96 Room Air 07/24/2019 |
| Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 |
| No: Appears Distressed, Appears in Pain |
| Exam Comments |
| Follow up evaluation done for inmate Epstein. He does not look in any pain or distress. He still has the erythema around his neck. Central part of this erythema has some abrasion. Patient does not complaint of any respiratory problem or distress. He still does not want to explain how the skin injury on his neck happed. he insinuates that injuries on his neck have to do with his room mate. But does not want to talk about it. ASSESSMENT: |
Injury, unspecified, T1490 - Current¶
PLAN:¶
Disposition:¶
Generated 07/24/2019 13:24 by Bureau of Prisons - NYM Page 1 of 2¶
| EPSTEIN, JEFFREY EDWARD Inmate Name: Date of Birth: 01/20/1953 Encounter Date: 07/24/2019 13:08 | Race: WHITE Sex: M Provider: | Reg #: 76318-054 Facility: NYM H01 Unit: | |
|---|---|---|---|
| Follow-up at Sick Call as Needed | |||
| Patient Education Topics: | |||
| format Pate Initiated | Handout/Topic | Provider | Outcome |
| Counseling 07/24/2019 | Access to Care | Verbalizes Understanding | |
| Counseling 07/24/2019 | Preventive Health | Verbalizes Understanding | |
| Copay Required:No | Cosign Required: Yes | ||
| TelephoneNerbal Order: No | |||
| on 07/24/2019 13:24 Completed by | |||
| Requested to be cosigned by | MD. |
Cosign documentation will be displayed on the following page.¶
Generated 07/24/2019 13:24 by Bureau of Prisons • NYM¶
CONFIDENTIAL SDNY_0000941 EFTA00033817¶
Bureau of Prisons Health Services Cosign/Review¶
| Inmate Name: Date of Birth: | EPSTEIN. JEFFREY EDWARD 01/20/1953 Encounter Date: 07/24/2019 13:08 | Sex: Provider: | • | Reg #: Race: Facility: | 76318-054 WHITE NYM | |
|---|---|---|---|---|---|---|
Cosigned with New Encounter Note by MD on 07/24/2019 16:10.¶
Bureau of Prisons - NYM¶
| Inmate Name: Date of Birth: Encounter Date: 07/23/2019 06:20 | 01/20/1953 | EPSTEIN, JEFFREY EDWARD | M Sex: Provider: | Race: WHITE | Reg #: Facility: NYM Unit: | 76318-054 H01 |
|---|---|---|---|---|---|---|
| SUBJECTIVE: | Injury Assessment - Non-work related encounter performed at Health Services. | |||||
| INJURY 1 | Provider: | |||||
| Date of Injury: | 07/23/2019 01:27 | Date Reported for Treatment: | 07/23/2019 08:25 | |||
| Work Related: No | Work Assignment: | UNASSG | ||||
| Pain Location: | ||||||
| Pain Scale: | 0 | |||||
| Pain Qualities: | ||||||
| Where Did Injury Happen (Be specific as to location): | ||||||
| Special Housing Unit Z05-Cell 124 L | ||||||
| Cause of Injury (Inmate’s Statement of how injury occurred): | ||||||
| ‘I do not know. Just went to drink a little water and wake up snorting’. | ||||||
| Symptoms (as reported by inmate): | ||||||
| None | ||||||
| OBJECTIVE: Temperature: | ||||||
| Time | Fahrenheit | Location Celsius | provider | |||
| D.BIt 07/23/2019 | 06:30 NYM | 97.5 | 36.4 Oral | |||
| Pulse: | ||||||
| Pitt | Time | Rate Per Minutq | Location | Rhythm | Provider | |
| 07/23/2019 06:30 | 92 | Via Machine | Regular | • | ||
| Respirations: | ||||||
| Data | Time | Rate Per Minute | Provider | |||
| 07/23/2019 | 06:30 NYM | 16 | • | |||
| Blood Pressure: | ||||||
| Data | Time 07/23/2019 06:30 NYM 140/85 | Location Value Right Arm | Position Sitting | Cuff Size Adult-regular | Provider | • |
| SaO2: | ||||||
| Drift 07/23/2019 | it 06:30 NYM | Valuer/01 Air 96 Room Air | Provider | |||
| Exam: | ||||||
| General | ||||||
| Affect | ||||||
| Yes: Cooperative | ||||||
| Appearance | ||||||
| Yes: Appears Well, Alert and Oriented x 3 | ||||||
| No: Appears Distressed, Lethargic, Dyspneic, Appears in Pain, Pallor, Cyanotic, Diaphoretic, Disheveled, | ||||||
| Generated 07/23/2019 09.05 by | bureau of Prisons • NYM | Page 1 of 2 |
CONFIDENTIAL SDNY_00009413¶
Exam:¶
Acutely III¶
Pulmonary¶
Auscultation¶
Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally¶
No: Crackles, Rhombi, Wheezing¶
Exam Comments¶
Inmate for injury report as requested by Operational Lt.¶
He is ambulatory, oriented x 3. In not apparent distress, smiling during this clinical encounter. Alleges, that he does not know what happened. Can not explain the marks on his neck. Responded: “I don’t know”.¶
He does not want to talk of the events leading to the marks on his neck.¶
He does not look in any distress or pain.¶
Has an circular line of erythema at the base of the neck. Reaching 2/3 of the neck circumference, 2 inches wide, sparing the back of the neck. Has one section of this erythema in the front with marks of friction.¶
No inflammation, no deformities, no hematomas, no lacerations, no tenderness. Patient moving his neck without any restriction. Denies having any pain or discomfort. Denies any respiratory problem.¶
Has another small erythema on left knee about 2cm in diameter(mild).¶
As per information from custody staff inmate Epstein was found in his cell with a rope around his neck and sitting on the floor.¶
Inmate is currently placed on suicide watch.¶
ASSESSMENT:¶
Injury, unspecified, T1490 - Current - R/O self inflicted injuries.¶
PLAN:¶
Disposition:¶
Follow-up at Sick Call as Needed Placed on Suicide Watch Follow-up in 2-4 Hours¶
Other:¶
For follow up with psychology service.¶
Patient Education Topics:¶
| Date Initiated Format 07/23/2019 | Counseling | Handout/Tooic Access to Care | Outcome Verbalizes Understanding |
|---|---|---|---|
| 07/23/2019 | Counseling | Plan of Care | Verbalizes Understanding |
| Copay Required:No | Cosign Required: Yes | ||
| TelephoneNerbal Order: No | |||
| Completed by | on 07/23/2019 09:05 | ||
| Requested to be cosigned by | MD. | ||
| Cosign documentation will be displayed on the following page. | |||
Generated 07/23/2019 09:05 by IMM.¶
Bureau of Prisons Health Services Cosign/Review¶
| Inmate Name: | EPSTEIN, JEFFREY EDWARD | Reg #: | 76318-054 | ||
|---|---|---|---|---|---|
| Date of Birth: | 01/20/1953 Encounter Date: 07/23/2019 06:20 | Sex: Provider. | M | Race: Facility: | WHITE NYM |
Cosigned by MD on 07/23/2019 15:44.¶
Bumau of Prisons - NYM¶
| Inmate Name: | EPSTEIN, JEFFREY EDWARD | Reg #: | 76318-054 | |||
|---|---|---|---|---|---|---|
| Date of Birth: | 01/20/1953 | Sex: | M | Race: WHITE | Facility: NYM | |
| Encounter Date: 07/14/2019 17:36 | Provider: | MD | Unit: | Z05 |
Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE:¶
| COMPLAINT 1 | Provider: | MD | |||||
|---|---|---|---|---|---|---|---|
| Chief Complaint: ENDO/LIPID | |||||||
| Subjective: 66 YR OLD WHITE MALE WITH HX OF HYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , NOW 431. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS DUE TO THEIR GI SIDE EFFECTS. HX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE FBI LOKELY HAS L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES. SURGICAL HX: NONE MENTAL HEALTH HX: NONE | |||||||
| 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): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid Added to clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid¶
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 Generals 07/14/201918:11 by MD Bureau of Prisons - NYM Page 1 of 3¶
Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/14/2019 17:36 Provider:¶
M Race: WHITE¶
Reg #: 76318-054 Facility: NYM MD Unit: Z05¶
Exam:¶
Eyes¶
General¶
Yes: PERRLA, Extraocular Movements Intact¶
Pulmonary¶
Auscultation¶
Yes: Clear to Auscultation¶
Cardiovascular¶
Auscultation¶
Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2¶
No: M/R/G¶
Abdomen¶
Auscultation¶
Yes: Normo-Active Bowel Sounds¶
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: mt Medication Omega 3 ( Vascepa) 1 GM Capsule¶
Order Date 07/14/2019 17:36¶
Prescriber Order¶
TAKE 2 CAPS Orally - Two Times a Day x 180 day(s) — TAKE WITH FOOD.¶
Indication: Hyperlipidemia, unspecified¶
New Laboratory Requests: Details Frequency¶
Lab Tests-H-Hemoglobin A1C One Time Lab Tests-L-Lipid Profile Additional Information: Generated 07/14/2019 18:11 by MD Bureau of Prisons - NYM¶
rilictPata Priority 10/10/2019 00:00 Routine¶
Page 2 of 3¶
CONFIDENTIAL SDNY_00009417¶
| EPSTEIN, JEFFREY EDWARD Inmate Name: Date of Birth: 01/20/1953 Encounter Date: 07/14/2019 17:36 | Sex: M Provider: | Reg #: Facility: NYM Race: WHITE MD Unit: | 76318-054 Z05 | ||||
|---|---|---|---|---|---|---|---|
| FASTING. Lab Tests-H-Hep B surface Ab Lab Tests-H-Hep B surface Ag Lab Tests-H-Hep C Ab Lab Tests-H-Hepatic Profile | One Time | 08/08/2019 00:00 | Routine | ||||
| Schedule: | |||||||
| Activity | Date Scheduled | Scheduled Provider | |||||
| Clinical Encounter | 07/24/2019 00:00 | Optometrist | |||||
| 66 YR OLD MALE FOR ROUTINE SCREENING. | |||||||
| Chronic Care Visit 6 MONTH F/U. | 01/07/2020 00:00 | Mid-Level Provider | |||||
| Chronic Care Visit | 07/01/2020 00:00 | Physician 01 | |||||
| Other: | |||||||
| PENDING EKG AND FOBT. CXR WAS REFUSED. | |||||||
| Patient Education Topics: | |||||||
| Pate InitiatedFormat 07/14/2019 Counseling | Handout/Tonic Diagnosis | Outcome Verbalizes Understanding | |||||
| Copay Required:No | Cosign Required: No | ||||||
| TelephoneNerbal Order: No | |||||||
| Completed by MD on 07/14/2019 18:11 |
Page 3 of 3¶
CONFIDENTIAL SDNY_00009418 EFTA00033824¶