BP-S358.060 # U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS ## 7-24-2019 Date I JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): #### DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. ## The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. • NYM-NEW YORK MCC SEP 05 # U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-10-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): ### DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: 66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR. # The following treatment(s) was/were recommended: CHEST X-RAY Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: ## WORSENING THE CONDITION IF THERE IS ANY FINDINGS I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. | X-RAY | 7-10-2019 | | |--------------|-----------------|---------------------| | Counseled by | Date | Patien
Signature | | | q,
(
Date | NYM-NEW YORK MCC | Date NYM-NEW YORK MCC SEP 05 ## BP-5358.060 MEDICAL TREATMENT REFUSAL CDFRM 4 ## U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS # 7-24-2019 Date JEFFREY EPSTEIN 76318-054 refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. #### The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. Counseled by Dale 7-24-2019 Pa nt's Si Date NYM--NEW YORK MCC # BP-A0618 - # A&O DENTAL EXAMINATION . FEDERAL BUREAU OF PRISONS (Initial Clinical Dental Findings) JUN 16 U.S. DEPARTMENT OF JUSTICE | | Occlusion: | | | | |----------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------|-----------------|--------------------------------|------| | | | | | | | | Oral Hygiene: | Good | Fair | Goor | | | CPITN: | | 7 | 3 | | | Head & Neck / Soft Tissue: | | | | | 7
8 10 11 12 13
6
8
2
3
ર્
4
G
32
31
29 28 27 26 25 24 23 22 21 20
30
19 - 18 | | | | | | | 0 | Classification: | | | | | Wi | | | | | | | Pain Scale: | | | | | | | /10 | | | Dental Prostheses at Intake: | | | | | | | | | | | | Yes
No
Type: | | | | | | Age:
Condition: | | | | | | Intra-oral Photos Taken: | Radiographs Taken: (Document findings on A&O encounter) | | | | | Yes | Yes | | | | | | No | | | | | | | | | | | Instructed how to obtain urgent and non-urgent dental care:
Yes: | | No: | | | | Treatment Priorities:
None: | Non-urgent: | | Urgent: Referred to Sick Call: | | | | non-urgent | | | | | Radiographs authorized: | Prophylaxis authorized: | | NO | | | PAS:
BWS
Panorex | (Approval valid 18 months from examination date) | | | | | Patient Name: | Der | DDS | | | | Register Number:
Institution | Date: | | Signature Block/Stamp: | | | MCC NEW YORK | 7-26-19. | | DDS. | | | | | | Chief Dental Officer | | | | | | MCC New York | | Prescribed by P6400 · Replaces BP-A0618 of JUN 10 1 ## BP-A0618 # A&O DENTAL EXAMINATION (Initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS JUN 16 U.S. DEPARTMENT OF JUSTICE Prescribed by P6400 · Replaces BP-A0618 of JUN 10 # OP-S358.060 MEDICAL TREATMENT REFUSAL COFRM SEP 05 # U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I, JEFFREY EPSTEIN 76318-054 refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. 7-24-2019 Dale S Date NYM-NEW YORK MCC | Federal
Bureau of
Prisons | U.S. Medical Center for Federal Prisons
1900 W. Sunshine Street
Springfield, MO 65807
417-874-1621 | | | | |----------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------|----------------------------------|--|--| | | | "' Sensitive But Unclassified "" | | | | Name EPSTEIN, JEFFREY | Facility
MCC New York | Collected 07/09/2019 13:34 | | | | Reg # 76318-054 | Order Unlit | Received 07/10/2019 10:44 | | | | DOB
01/20/1953 | Provider
MD | Reported 07/10/201914:46 | | | | M
Sex | | LIS ID
188191004 | | | | | HIV | | | | | HIV 1/2 | Negative | Negative | | | | Screening test - See confirmatory testing for Reactive results | | | | | FLAG LEGEND L=Low L!=Low Critical H=High H!=High Critical A=Abnormal A! =Abnormal Critical Page 3 of 3 # Bureau of Prisons Health Services Cosign/Review | Inmate Name: | EPSTEIN, JEFFREY EDWARD | | | Reg #: | 76318-054 | |----------------|----------------------------------|-----------|--------------------|-----------|-----------| | Date of Birth: | 01/20/1953 | Sex: | M | Race: | WHITE | | | Encounter Date: 07/10/2019 16:58 | Provider: | Lab Result Receive | Facility: | NYM | Cosigned by on 07/14/2019 18:12. # BP-S358.060 MEDICAL TREATMENT REFUSAL CDFRM F ## U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I, JEFFREY EPSTEIN 76318.054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my ex ressed wishes and directions. | 7-24-2019
Date | is Sign
Pa | Date | |-------------------|------------------|------| | fi
427Date | NYM-NEW YORK MCC | | # BP-A0618 JUN 16 # A&O DENTAL EXAMINATION (Initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE ### FEDERAL BUREAU OF PRISONS | Dental Prostheses at Intake:
Yes | | |-------------------------------------------------------------|--------------------------------------------------| | No
Type: | | | Age:
Condition: | | | Intra-oral Photos Taken: | raphs Taken: (Document findings on A&O encounte | | Yes | Yes | | | No | | Instructed how to obtain urgent and non-urgent dental care: | Yes:
No: | | Treatment Priorities:
None: | Non-urgent:
Urgent: Referred to Sick Call: | | | non-urgent | | Radiographs authorized: | Prophylaxis authorized:
No | | PAS: | (Approval valid 18 months from examination date) | | BWG | | | | | | Patient Name: | Dentist | | | | | | Date:
Signature Block/Stamp: | | MCC NEW YORK | 7-26-19.
DDS. | | | Chief Dental Officer | | | MCC New York | PDF Prescribed by P6400 Replaces BP-A0618 of JUN 10 1 COFRM # U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatments) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. | 7-24-2019
Date | is Sig
Pa | Date | |-------------------|------------------|------| | t19
Date | NYM-NEW YORK MCC | | SEP 05 # BP-S358.060 MEDICAL TREATMENT REFUSAL CDFRM ## U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS # 7-10-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): ## DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: 66 YR OLD MALE WITH NO PIVIHX , REFERRED FOR ROUITNE CXR. # The following treatment(s) was/were recommended: CHEST X-RAY Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: ## WORSENING THE CONDITION IF THERE IS ANY FINDINGS I understand tho possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. | X-RAY | 7-10-2019 | | |--------------|------------|----------------------| | Counseled by | Date | Patient
Signature | | | | | | ES±li | cr
Date | NYM-NEW YORK MCC | | | | | Date # BP-A0618 JUN 16 U.S. DEPARTMENT OF JUSTICE - # A&O DENTAL EXAMINATION (Initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS | | | Occlusion: | | | | |-------------------------------------------------------------|----------|---------------------------------------------------------|-----------------|--------------------------------------|------| | | | Oral Hygiene: | Good | Fair | Poor | | | | CPITN: | | 2
O | a) | | 9 10 11 12 13
5
7
हि
B
2
3 | 15
14 | Head & Neck / Soft Tissue: | | | | | 29 28 27 26 25 24 23 22 21 20
31
30 | 19 . 18 | | Classification: | | | | | | 00 | | | | | | | | Pain Scale: | /10 | | | | | | | | | | Dental Prostheses at Intake:
No
Yes
Type:
Age: | | | | | | | Condition:
Intra-oral Photos Taken: | | Radiographs Taken: (Document findings on A&O encounter) | | | | | Yes | Yes | | | | | | | No | | | | | | Instructed how to obtain urgent and non-urgent dental care: | yes: | | No: | | | | Treatment Priorities:
None: | | Non-urgent:
non-urgent | | Urgent: Referred to Sick Call: | | | Radiographs authorized: | | Prophylaxis authorized: | | No | | | PAS:
BVW | | (Approval valid 18 months from examination date) | | | | | Institution | | Dentis
Date: | 2015 | Signature Block/Stamp: | | | MCC NEW YORK | | 7-26-19. | | DDS. | | | | | | | Chief Dental Officer
MCC New York | | | | | | | | | Prescribed by P6400 Replaces BP-A0618 of JUN 10 1 # Bureau of Prisons Health Services Clinical Encounter | Inmate Name:
01/20/1953
Date of Birth:
Encounter Date: 08/1012019 07:25 | EPSTEIN, JEFFREY EDWARD | M
Sex:
Provider: | Race: WHITE
RN | Reg #:
76318-054
Facility: NYM
Unit:
Z04 | | | |----------------------------------------------------------------------------------|------------------------------------------------------------------------------------------|------------------------|-------------------|------------------------------------------------------|--|--| | | Emergency Code - Resuscitation Event encounter performed at Special Housing Unit. | | | | | | | SUBJECTIVE: | Provider: | | | | | | | Emergency Note | | RN | | | | | | Team Members: | | | | | | | | Provider | | Ha& | | | | | | | RN | Team/Code Leader | | | | | | Code Events: | | | | | | | | Tvoe | Value | | Date | | | | | CPR | Compressions | | | 08/10/2019 06:35 | | | | EKG/Monitor | Lifepak | | | 08/10/201906:39 | | | | No shock advised | | | | | | | | CPR | Compressions | | | 08/10/2019 06:40 | | | | Oxygen | 15L | | | 08/10/201906:47 | | | | IV Access | Peripheral IV | | | 08/10/2019 06:48 | | | | 18g Left AC | | | | | | | | Airway | Endotracheal Tube | | | 08/10/2019 07:08 | | | | | ET Tube 7.5 24CM to L Lip line Placed by Paramedics | | | | | | | Medications | Epinephrine 1mg IV | | | 08/10/201907:10 | | | | CPR | Epinephrine 3 doses and Sodium bicarb 2 doses administered by paramedics
Compressions | | | 08/10/2019 07:11 | | | | | Sodium Bicarbonate 1 mEa/kg IV | | | | | | | Medications | | | | 08/10/2019 07:11 | | | | IV Fluids | Normal Saline 0.9% 1000 ml | | | 08/10/2019 07:12 | | | | Medications | Epinephrine 1mg IV | | | 08/10/2019 07:13 | | | | CPR | Compressions | | | 08/10/2019 07:14 | | | | Medications | Sodium Bicarbonate 1 mEa/kg IV | | | 08/10/2019 07:14 | | | | Medications | Epinephrine 1mg IV | | | 08/10/2019 07:16 | | | | CPR | Compressions | | | 08/10/2019 07:17 | | | #### Comments: Responded to a body alarm at 0635 for medical emergency on 9S, Upon arrival Inmate was received on the floor of his cell unresponsive with CPR in progress by correctional officers, Inmate was Cold, with circumferential Bruising around the neck and posterior mottling, Pupils Fixed and dilated. No Palpable pulses, Call place for EMS, CPR Continued, AED Placed No shock advised, CPR Continued, inmate transported to HSU treatment room with CPR in progress, 18g hep lock to L AC, O2 15 Lt ViA BVM, Pulse Check NO SHOCK advised. EMS and Paramedics arrived 0656, Placed on cardiac monitor asystole Resumed CPR, Inmate was intubated by Medics, 3 Rounds of Epinephrine administered, Pulse Check asystole, Inmate was transported to Local ER with CPR in progress. #### OBJECTIVE: Exam: #### General Appearance Yes: Unconscious Generated 08110/2019 06:10 by RN Bureau of Prisons - NYM Page 1 of 2 | Inmate Name:
EPSTEIN, JEFFREY EDWARD
Date of Birth:
01/20/1953
Encounter Date: 08/10/2019 07:25 | | Sex:
Provider: | M | Race: WHITE | RN | Reg #:
Facility: NYM
Unit: | 76318-054
Z04 | | |-------------------------------------------------------------------------------------------------------------|------------------------|-------------------|-----------------------|-------------|----------|----------------------------------|------------------|----------| | Exam: | | | | | | | | | | ASSESSMENT: | | | | | | | | | | Cardiac Arrest | | | | | | | | | | PLAN: | | | | | | | | | | New Consultation Requests: | | | | | | | | | | Consultation/Procedure | Target Date | | Scheduled Target Date | | Priority | | Translator | Ianauage | | Emergency Room | 08/10/2019 | | 08/10/2019 | | Emergent | | No | | | Subtype: | | | | | | | | | | AMBULANCE | | | | | | | | | | Reason for Request: | | | | | | | | | | Cardiac arrest with CPR In progress | | | | | | | | | | Copay Required:No | Cosign Required: Yes | | | | | | | | | TelephoneNerbal Order: No | | | | | | | | | | Completed by | RN on 08/10/2019 08:10 | | | | | | | | | Requested to be cosigned by | | | | | | | | | Cosign documentation will be displayed on the following page. # 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: 07/30/2019 15:58 | Provider. | | | Unit: | Z01 | Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT WAS REFERRED BY THE WARDEN FOR EVALUATION. PATIENT REPORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO REPORTS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STATES THE NUMBNESS WENT AWAY ON ITS OWN. BUT WAS VERY CONCERNING. HE DENIES RIGHT SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OR SWALLOWING. HE REPORTS NOCTURIA OF ABOUT 5 TIMES.. HE DENIES DYSURIA. HE REPORTS H OF KIDNEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEP APNEA AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HERE SINCE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE RECEIVED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-MEDICAL ISSUES. STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Seen for clinic(s): Pulmonary/Respiratory, Orthopedic/Rheumatology, Endocrine/Lipid #### OBJECTIVE: #### Exam: General #### Affect Yes: Cooperative #### 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 #### Pulmonary Auscultation Yes: Clear to Auscultation #### Cardiovascular #### Auscultation Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2 No: M/R/G ## Musculoskeletal ## Tibia / Fibula No: Edema ## Neurologic Ginersted 07/30/2019 16:12 by Bureau of Prisons • NYM Pop 1 of 2 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 15:58 Provider. Reg #: 76318-054 Facility: NYM Unit: Z01 | Exam: | | | | |------------------------|----------------------------------------------------------|-------------------------|-------------------------------------------------------------| | | Cranial Nerves (CN) | | | | | Yes: Within Normal Limits | | | | | Motor System-General | | | | | Yes: Normal Exam | | | | | Motor System-Strength | | | | | Yes: Normal Muscular Strength | | | | ASSESSMENT: | | | | | | Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current | | | | | Constipation, unspecified, K5900 - Current | | | | | Essential (primary) hypertension, 110 - Current - BY HX. | | | | | Hyperlipidemia, unspecified, E785 - Current | | | | | Low back pain, M545 - Current | | | | | Neuralgia and neuritis, unspecified, M792 - Current | | | | | Prediabetes, R7303 - Current | | | | | Sleep apnea, G4730 - Current | | | | PLAN: | | | | | | | | | | New Medication Orders: | Medication | Order Date | Prescriber Order | | | INsulin REG - Human | 07/30/2019 15:58 | SLIDING SCALE | | | | | Subcutaneously each morning x
7 day(s) Pill Line Only | | | Indication: Prediabetes | | | | | Discontinued Medication Orders: | | | | Bat | Medication | Order Date | Prescriber Order | | 122148-NYM | Insulin Reg (10 ML) 100 UNITS/ML Inj | 07/30/2019 15:58 | Inject regular insulin
subcutaneously per sliding scale: | | | | | twice daily "pill line"' for 7
days | | | Discontinue Type: | When Pharmacy Processes | | | | Discontinue Reason:new order written | | | | | Indication: | | | Copay Required: No TelephoneNerbal Order: No Cosign Required: No on 07/30/2019 16:12 Completed by # 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: 07/30/2019 11:12 | Provider: | | | Unit: | 201 | Chronic Care • Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: | COMPLAINT 1 | | Provider: | | | | | | | | |----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------|-----------|-------------------------------|---------------------|-----------|---------------------|-------------|--|--| | Chief Complaint: Other Problem | | | | | | | | | | | Subjective:
S REFERRED BY THE WARDEN FOR EVALUATION.
PATIENT
RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE
PATIEN
S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO.
ALSO
BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING.
STAT
SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY
HE DENI
SPEAKING
OWING.
IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA.
HE REPORT
NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING
HE REPORTS H
TOPROL.
AND STATED HE HAS NOT SLEPT FOR 3 WEEKS
HE AHS A HX OF SLEEP
CE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I
ISNCE HE HASB EEN
HIS CPAP MACHINE AND IT WILL BE GIVEN TO
INFORME DHIM THAT WE R
HIM TONIGHT
HE REPORT OTHER NON-ME
STATES HE FEELS OTHERWISE | | | | | | | | | | | Pain: | Not Applicable | | | | | | | | | | Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology. | | | | | | | | | | | OBJECTIVE:
Pulse: | | | | | | | | | | | DAM | Time | | Rate Per Minute | Location | | Provider | | | | | 07/30/2019 13:02 | | | 94 | | | eaudouin, Robert MD | | | | | 07/30/2019 09:40 | | | 88 | Via Machine | | ouin, Robert MD | | | | | 07/30/2019 09:30 | | | 87 | Via Machine | | Robed MD | | | | | Respirations: | | | | | | | | | | | Date | Time | | Rate Per Minute | provider | | | | | | | 07/30/2019 | 09:30 NYM | | | 12 | | | | | | | Blood Pressure: | | | | | | | | | | | =St | Time | Mks | Location | Position | Cuff Size | provider | | | | | | 07/30/2019 13:02 NYM 114/84 | | Left Arm | Standing | | | | | | | | 07/30/2019 09:40 NYM 125/60 | | Right Arm | Standing | | | | | | | | 07/30/2019 09:30 NYM 108/86 | | Left Arm | Sitting | | | | | | | SaO2: | | | | | | | | | | | pate
07/30/2019 | lime
09:30 NYM | | NtaltLet%1 Air
98 Room Air | | Elnyld_er | | | | | | Weight: | | | | | | | | | | | Date | Time | | Was | Kg Waist Circum. | | | | | | | Gonoralod 07/30201914:05 by | | | | &MOM of Prisons NYM | | | Pogo 1 of 3 | | | | Inmate Name:
Date of Birth:
Encounter Date: 07/30/2019 11:12 | EPSTEIN, JEFFREY EDWARD
01/20/1953 | | Sex:
Provider: | Race: WHITE
M | Reg #:
Facility: NYM
Unit: | 76318-054
201 | | |--------------------------------------------------------------------|-----------------------------------------------------------------|---------------|-------------------|------------------|----------------------------------|--------------------------------------------------------------------------------------|--| | Date | Time | Lim | Kg Waist Circum | Provider | | | | | 07/30/2019 | 09:30 NYM | 194.2
88.1 | | | | | | | Exam: | | | | | | | | | General | | | | | | | | | Affect | | | | | | | | | | Yes: Cooperative | | | | | | | | Appearance | | | | | | | | | | Yes: Appears Well, Alert and Oriented x 3
No: Appears Distre | | | | | S. Dyspneic, Appears in Pain, Writhing in Pain. Pale, Pallor, Cyanotic, Diaphoretic, | | | Nutrition | Disheveled, Unk | cutely III | | | | | | | | No: Appears Ob | | | | | | | | Pulmonary | | | | | | | | | Auscultation | | | | | | | | | | Yes: Clear to Auscultation | | | | | | | | Cardiovascular | | | | | | | | | Auscultation | Yes: Regular Rate and Rhythm (RRR | | | 1 and S2 | | | | | | No: M/R/G | | | | | | | | Musculoskeletal | | | | | | | | | Tibia / Fibula | | | | | | | | | | No: Edema | | | di) | | | | | Neurologic | | | | | | | | | Cranial Nerves | (CN)
Nor
Yes: Within Normal Limits | | | | | | | | | Motor System-General | | | | | | | | | Yes: Normal Exam | | | | | | | | | Motor System-Strength | | | | | | | | | Yes: Normal Muscular Strength | | | | | | | | ASSESSMENT: | | | | | | | | | | Body mass index (BMI) 27.0-27.9, adult, 26827 - Current | | | | | | | | | Constipation, unspecified. K5900 - Current | | | | | | | | | Essential (primary) hypertension. 110 - Current - BY HX. | | | | | | | | | Hyperlipidemia, unspecified, E785 - Current | | | | | | | | | Low back pain, M545 - Current | | | | | | | | | Neuralgia and neuritis, unspecified, M792 - Current | | | | | | | | Prediabetes. R7303 - Current | | | | | | | | | Sleep apnea. G4730 - Current | | | | | | | | | PLAN: | | | | | | | | | New Medication Orders: | | | | | | | | | ⁢ | accusation | | | Order Date | | Prescriber Order | | | | | | | | | | | Generated 07/30/2019 14:05 by Bureau of Prisons • NYM Page 2 of 3 | Inmate Name:
Date of Birth: | EPSTEIN. JEFFREY EDWARD
01/20/1953
Encounter Date: 07/30/2019 11:12 | Sex:
Provider: | M
Race: WHITE | | Reg #:
Facility: NYM
Unit: | 76318-054
Z01 | | |--------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------|----------------------------------|------------------------------|-----------------------------------------------------------------------|--------------------------------------------------------------------------------|----------------------------------------| | New Medication Orders: | | | | | | | | | Rx# | Me itc_ation
Magnesium Hydroxide Susp conc 800
MG/5ML
Indication: Constipation, unspecified | | Oider_Cia Se
07/30/2019 11:12 | | Prescriber Order
10 CC Orally - Two Times a
Day PRN x 90 day(s) | | | | | INsulin REG - Human
Indication: Prediabetes | | 07/30/2019 11:12 | | | SLIDING SCALE
Subcutaneously - Two Times a
Day x 7 day(s) Pill Line Only | | | Renew Medication Orders: | | | | | | | | | F#c
121836-NYM | Medication
methylPR
Pack)
Indication: y= z11 is and neuritis, unspecified | ne 4 MG Tab ( 21 count | Order Date
07/30/2019 11:12 | | | Prescriber Order
Take the tablet by mouth as
directed x 6 day(s) | | | New Laboratory Requests:
Details
Lab Tests-U-Uric Acid | Lab Tests - Short List-General-CBC w/diff
Lab Tests-P-PSA, Total
Lab Tests - Short List-General-Comprehensiv
Metabolic Profile (CMP)
Lab Tests-U-Urinalysis w/Reflex to Microscopic
New Radiology Request Orders: | Frequency
ne Time | | Due Date
08/01/2019 00:00 | | Priority
Routine | | | Details | | Ernwency | | | Due Date | Priority | | | General | General Radiology-Spine / Cervical | One Time | | | 08/29/2019 | Routine | | | | Specific reason(s) for request (Complaints and findings): | | | | | | | | | 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI
PLEASE PERFORM C SPINE SERIES | | | | | R 2-3 MINUTES 3 DAYS AGO. | | | Disposition: | | | | | | | | | | Follow-up at Sick Call as Needed | | | | | | | | Patient Education Topics: | | | | | | | | | Date Initiated
07/30/2019 | Format
Counseling | Handout/Topic
Access to Care | | | | | Outcome
Verbalizes
Understanding | | 07/30/2019 | Counseling | Plan of Care | | | | | Verbalizes
Understanding | | Copay Required:No
TelophoneNerbal Order: No | | Cosign Required: No | | | | | | | Completed by | | on 07/30/2019 14:05 | | | | | | # 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: 07/30/2019 11:12 | Provider: | | | Unit: | 201 | Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: | COMPLAINT 1 | | Provider: | | | | | | |---------------------------------------------------------------|---------------------------------------------------------------------------------|--------------------------------------------------|------------------------------------------------------------------------------------------------|---------------------------|----------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------| | | Chief Complaint: Other Problem | | | | | | | | Subjective: | PATIENT
PATIE
ALSO
STAT
HE DENI
SPEAKING
HE REPORT
TOPROL. | HE REPORTS H
ISNCE HE HASB EEN
HIM TONIGHT | OWING.
- -
INFORME DHIM THAT WE R
HE REPORT OTHER NON-ME
STATES HE FEELS OTHERWISE | ES. | S REFERRED BY THE WARDEN FOR EVALUATION.
'VIA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. | RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE
S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO.
BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING.
SIDED WEAKNESS, DIPLOPIA. FACIAL DROOP, DIFFICULTY
a NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING
HE AHS A HX OF SLEEP .;,t•-ti.fx.t• AND STATED HE HAS NOT SLEPT FOR 3 WEEKS
-••9i,tCE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I
HIS CPAP MACHINE AND IT WILL BE GIVEN TO | | | Pain: | Not Applicable | | | | | | | | Seen for clinic(s): Endocrine/Lipid. Orthopedic/Rheumatology, | | | | | Respiratory | | | | OBJECTIVE: | | | | | | | | | Pulse: | | | | | | | | | Date | Time | | Rate Per Minute | lac_atiort | | | | | 07/30/2019 13:02 | | | 94 | | | | MD | | 07/30/2019 09:40 | | | 88 | Via Machine | | | MD | | 07/30/2019 09:30 | | | 87 | Via Machine | | | MD | | Respirations: | | | | | | | | | Date | Time | | Rate Per Minute | Provider | | | | | 07/30/2019 | 09:30 NYM | | | 12 | | | | | Blood Pressure: | | | | | | | | | Date | im | Value | Location | Position | Cuff Size | Provider | | | | 07/30/2019 13:02 NYM 114/84 | | Left Arm | Standing | | | | | | 07/30/2019 09:40 NYM 125/60 | | Right Arm | Standing | | | | | | 07/30/2019 09:30 NYM 108/86 | | Left Arm | Sitting | | | | | Sa02: | | | | | | | | | Date
07/30/2019 | Time
09:30 NYM | | Air
Value(%)
98 Room Air | | Provider | | | | Weight: | | | | | | | | | Dat€ | Time | | L1)s. | Kg Waist Circum | Provider | | | | Generated 07/30/2019 14:05 by | | | | Ehlteall of Prisons • NYM | | | Page 1 of 3 | | Inmate Name:
Date of Binh: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/30/2019 11:12 | | Sex:
Provider: | M
Race: WHITE | Reg #:
Unit: | 76318-054
Facility: NYM
Z01 | |----------------------------------------|---------------------------------------------------------------------------|----------------|--------------------------|------------------|-----------------|---------------------------------------------------------------------------------------| | Data
07/30/2019 | Time
09:30 NYM | Lila.
194.2 | Ka Walett.Cirons
88.1 | provider | | | | Exam:
General
Affect | | | | | | | | | Yes: Cooperative | | | | | | | Appearance | | | | | | | | | Yes: Appears Well, Alert and Oriented x 3 | | | | | | | Nutrition
Pulmonary
Auscultation | No: Appears Distre
Disheveled, linke
No: Appears Obw | cutely III | | | | ed, Dyspneic. Appears in Pain, Writhing in Pain, Pale, Pallor. Cyanotic, Diaphoretic, | | | Yes: Clear to Auscultation | | | | | | | Cardiovascular
Auscultation | | | | | | | | | Yes: Regular Rate and Rhythm (RRR | | | and S2 | | | | | No: WR/G | | | | | | | Musculoskeletal | | | | | | | | Tibia I Fibula | | | | | | | | | No: Edema | | | | | | | Neurologic | | | | | | | | | Cranial Nerves (CN) | | | 411°) | | | | | Yes: Within Normal Limits | | | | 0 | | | | Motor System-General | | | | | | | | Yes: Normal Exam | | | | | | | | Motor System-Strength | | | | | | | | Yes: Normal Muscular Strength | | | | | | | ASSESSMENT: | | | | | | >d
ir | | | Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current | | | | | | | | Constipation, unspecified, K5900 - Current | | | | | | | | Essential (primary) hypertension, 110 - Current - BY HX. | | | | | | | | Hyperlipidemia, unspecified, E785 - Current | | | | | | | | Low back pain, M545 - Current | | | | | | | | Neuralgia and neuritis, unspecified, M792 - Current | | | | | | | | | | | | | | | | Prediabetes, R7303 - Current | | | | | | | | Sleep apnea, G4730 - Current | | | | | | | PLAN: | | | | | | | | | | | | | | | New Medication Orders: Medication Order Date Prescriber Order Generated 07/30/2019 14:05 by Bureau of Prisons - NYM Page 2 of 3 | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953 | Sex: | Race: WHITE
M | | Reg #:
Facility: NYM | 76318-054 | | |------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------|--------------------------------|---------------------------------------------------|-------------------------|--------------------------------------------------------------------------------|----------------------------------------| | | Encounter Date: 07/30/2019 11:12 | Provider: | | | Unit: | Z01 | | | New Medication Orders:
Rx# | Medication. | | Order Date | | | Prescriber Order | | | | Magnesium Hydroxide Susp conc 800
MG/5ML | 07/30/2019 11:12 | | 10 CC Orally - Two Times a
Day PRN x 90 day(s) | | | | | | Indication: Constipation, unspecified
INsulin REG - Human | | 07/30/2019 11:12 | | | SLIDING SCALE
Subcutaneously - Two Times a
Day x 7 day(s) Pill Line Only | | | | Indication: Prediabetes | | | | | | | | Renew Medication Orders:
fix#
121836-NYM | Medication
methylP
Pack)
Indication: | ne 4 MG Tab ( 21 count
is and neuritis, unspecified | Order Date
07/30/2019 11:12 | | | Prescriber Order
Take the tablet by mouth as
directed x 6 day(s) | | | New Laboratory Requests: | | | | | | | | | Details | Lab Tests - Short List-General-CBC w diff
Lab Tests-P-PSA, Total
Lab Tests-U-Uric Acid
Lab Tests - Short List-General-Comprehensiv
Metabolic Profile (CMP)
Lab Tests-U-Urinalysis w/Reflex to Microscopic
New Radiology Request Orders: | Frequency
ro e Time | | Due Date
08/01/2019 00:00 | | Priority
Routine | | | Details | | Frequency | | Due Date | | Priority | | | General | General Radiology-Spine / Cervical- | One Time | | | 08/29/2019 | Routine | | | | Specific reason(s) for request (Complaints and findings): | | | | | | | | | 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI
PLEASE PERFORM C SPINE SERIES | | | | | R 2-3 MINUTES 3 DAYS AGO. | | | Disposition: | Follow-up at Sick Call as Needed | | | | | | | | Patient Education Topics: | | | | | | | | | Date Initiated
07/30/2019 | Format
Counseling | Handout/Tooic
Access to Care | | | | | Outcome
Verbalizes
Understanding | | 07/30/2019 | Counseling | Plan of Care | | | | | Verbalizes
Understanding | | Copay Required: No | TelephoneNerbal Order: No | Cosign Required: No | | | | | | | Completed by | | on 07/30/2019 14:05 | | | | | | Generated 07130/2019 14:05 by Bureau of Prisons NYM Page 3 of 3 # Bureau of Prisons Health Services See Amendment | EPSTEIN, JEFFREY EDWARD
Inmate Name:
Date of Birth:
01/20/1953
Encounter Date: 07/30/2019 15:58 | Sex: | M | Reg #:
Race:
Facility: | 76318-054
WHITE
NYM | | |-------------------------------------------------------------------------------------------------------------|------|---|------------------------------|---------------------------|--| |-------------------------------------------------------------------------------------------------------------|------|---|------------------------------|---------------------------|--| Amendment made to this note by on 07/30/201916:12.