Jail record · July 14, 2019

Jeffrey Epstein's routine medical exam record at MCC New York, July 2019

Bureau of Prisons medical encounter record documenting Epstein's chronic care screening exam, diagnoses including constipation and hyperlipidemia, new medication order, and follow-up labs.Machine-written summary

EFTA00059517¶

Inmate Name: EPSTEIN, JEFFREY EDWARD	Sex: M	Race: WHITE	Reg #: 76318-054
Date of Birth: 01/20/1953			Facility: NYM
Encounter Date: 07/14/2019 17:36	Provider:	MD	Unit: Z05

Exam:¶

Eyes¶

General¶

Yes: PERRLA, Extraocular Movements Intact¶

Pulmonary¶

Cardiovascular¶

Auscultation¶

Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2¶

No: M/R/G¶

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:
Rx#	Medication
	Omega 3 (Vascepa) 1 GM Capsule

Order Date
07/14/2019 17:36

Indication: Hyperlipidemia, unspecified¶

New Laboratory Requests:¶

Details¶

Lab Tests-H-Hemoglobin A1C¶

Lab Tests-L-Lipid Profile¶

Additional Information:¶

Generated 07/14/2019 18:11 by¶

Prescriber Order
TAKE 2 CAPS Orally - Two Times a Day x 180 day(s) – TAKE WITH FOOD.

Frequency¶

One Time¶

Bureau of Prisons - NYM¶

Due Date
10/10/2019 00:00

Priority¶

Routine¶

Page 2 of 3¶

EFTA00059518¶

Inmate Name: EPSTEIN, JEFFREY EDWARD	Sex: M Race: WHITE	Reg #: 76318-054
Date of Birth: 01/20/1953	Provider: MD	Facility: NYM
Encounter Date: 07/14/2019 17:36		Unit: 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¶

Schedule:¶

Activity Clinical Encounter 66 YR OLD MALE FOR ROUTINE SCREENING. Chronic Care Visit 6 MONTH F/U. Chronic Care Visit¶

Date Scheduled 07/24/2019 00:00 01/07/2020 00:00 07/01/2020 00:00¶

Scheduled Provider Optometrist Mid-Level Provider Physician 01¶

Other: PENDING EKG AND FOBT. CXR WAS REFUSED.¶

Patient Education Topics:¶

Date Initiated	Format	Handout/Topic	Provider	Outcome
07/14/2019	Counseling	Diagnosis	Beaudouin, Robert	Verbalizes Understanding

Copay Required: No Telephone/Verbal Order: No Completed by MD on 07/14/2019 18:11¶