Bureau of Prisons health services encounter records for Jeffrey Epstein, July 2019

EFTA00073866¶

Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/12/2019 13:10¶

Sex: Provider:¶

M Race: WHITE¶

Reg #:	76318-054
Facility:	NYM
Unit:	Z05

Follow-up at Sick Call as Needed¶

Other:¶

WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP.¶

Patient Education Topics:¶

| Date Initiated | Format |¶

| :--- | :--- |¶

| 07/12/2019 | Counseling |¶

Handout/Topic¶

Diagnosis¶

Provider¶

Copay Required: No	Cosign Required: No
Telephone/Verbal Order: No
Completed by Beaudouin, Robert MD on 07/12/2019 14:20

Outcome
Verbalizes
Understanding

Page 036 of 148¶

Withheld pursuant to exemption¶

(b) (6) ; (b)(7)(A) ; (b)(7)(C)¶

of the Freedom of Information and Privacy Act¶

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Page 3 of 3¶

Bureau of Prisons - NYM¶

EFTA00073867¶

Bureau of Prisons Health Services Clinical Encounter¶

Inmate Name: EPSTEIN, JEFFREY EDWARD¶

Date of Birth: 01/20/1953¶

Reg #: 76318-054¶

Race: WHITE¶

Sex:¶

Provider:¶

Facility: NYM¶

Encounter Date: 07/12/2019 13:10¶

Unit: Z05¶

Chronic Care - 14 Day Physician Eval encounter performed at Health Services.¶

SUBJECTIVE:¶

COMPLAINT 1 Provider:¶

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 | Page 037 of 148 |¶

| :--- | :--- | :--- |¶

Location:	Back-Middle	Withheld pursuant to exemption

Quality of Pain: Shooting¶

Pain Scale: 5¶

Intervention: MEDRO ROSERAGK of the Freedom of Information and Privacy Act¶

Trauma Date/Year:¶

Mechanism:¶

Onset:	5+ Years

Duration: 5+ Years¶

Exacerbating Factors: NO EXERCISE¶

Relieving Factors: MEDROL DOSE PACK¶

Reason Not Done:¶

Comments:¶

Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology¶

Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology¶

OBJECTIVE:¶

Exam:¶

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 Ill¶

Nutrition¶

No: Appears Obese¶

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Bureau of Prisons - NYM¶

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EFTA00073868¶

Inmate Name: EPSTEIN, JEFFREY EDWARD¶

Date of Birth: 01/20/1953¶

Encounter Date: 07/12/2019 13:10¶

Sex: Provider:¶

M Race: WHITE¶

Reg #:	76318-054
Facility:	NYM
Unit:	Z05

Exam:¶

Eyes¶

General¶

Yes: [ ] , Extraocular Movements Intact¶

Pulmonary¶

Auscultation

Yes: Clear to Auscultation

Cardiovascular¶

Auscultation¶

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

No: M/G¶

Abdomen¶

Auscultation¶

Yes: Normo-Active Bowel S¶

Palpation

Yes: Within Normal Limits

Musculoskeletal

Tibia / Fibula

No: Edema

Back

Yes: Tenderness

Neurologic
Cranial Nerves(CN)	(b)(6);(b)(7)(A);(b)(7)(C)
Yes:Within Normal Limits	of the Freedom of Information and Privacy Act
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
	Magnesium Hydroxide Susp

Order Date
07/12/2019 13:10

Prescriber Order
30 CC Orally - Two Times a Day PRN x 2 day(s)

Indication:	Constipation, unspecified
MethylPREDNISolone Tab 4 MG(Dose Pack 21 tab)	07/12/2019 13:10
Indication:	Neuralgia and neuritis, unspecified

AS DIRECTED Orally - daily x 6 day(s)¶

Disposition:¶

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Bureau of Prisons - NYM¶

Page 2 of 3¶

EFTA00073869¶

Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/12/2019 13:10¶

Sex: Provider:¶

M Race: WHITE¶

Reg #:	76318-054
Facility:	NYM
Unit:	Z05

Follow-up at Sick Call as Needed¶

Other:¶

WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP.¶

Patient Education Topics:¶

| Date Initiated | Format |¶

| :--- | :--- |¶

| 07/12/2019 | Counseling |¶

Handout/Topic¶

Diagnosis¶

Provider¶

Copay Required: No	Cosign Required: No
Telephone/Verbal Order: No
Completed by Beaudouin, Robert MD on 07/12/2019 14:20

Outcome
Verbalizes
Understanding

Page 039 of 148¶

Withheld pursuant to exemption¶

(b) (6) ; (b)(7)(A) ; (b)(7)(C)¶

of the Freedom of Information and Privacy Act¶

Generated 07/12/2019 14:20 by¶

Bureau of Prisons - NYM¶

Page 3 of 3¶

EFTA00073870¶