Jeffrey Epstein medical records from MCC New York, July 2019

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¶

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.¶

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.¶

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.¶

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		M	RN	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	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.¶