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Jail record · July 12, 2019

Bureau of Prisons medical encounter for Jeffrey Epstein at MCC New York, July 12, 2019

Bureau of Prisons chronic care physician evaluation recording Epstein's lipid, sleep apnea, and back pain complaints and prescribed medications.Machine-written summary

Bureau of Prisons Health Services Clinical Encounter

Inmate Name:EPSTEIN, JEFFREY EDWARDReg #:76318-054
Date of Birth:01/20/1953Sex:MRace:WHITEFacility:NYM
Encounter Date:07/12/2019 13:10Provider:MDUnit: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 437. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS DUE TO THEIR GI SIDE EFFECTS.

HX OF OBSTRUCTIVE 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):Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology
Added to clinic(s):Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology

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 Ill

No: Appears Obese

Generated 07/12/2019 14:20 by

Page 1 of 3

Bureau of Prisons - NYM

EFTA00110382

Inmate Name:EPSTEIN, JEFFREY EDWARD
Date of Birth:01/20/1953
Encounter Date:07/12/2019 13:10
Reg #:76318-054
Facility:NYM
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:
Rx#Medication
Magnesium Hydroxide Susp
Order Date
07/12/2019 13:10

Prescriber Order

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

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

AS DIRECTED Orally - daily x 6 day(s)

Disposition:

Generated 07/12/2019 14:20 by

Page 2 of 3

MD

Bureau of Prisons - NYM

EFTA00110383

Inmate Name: EPSTEIN, JEFFREY EDWARDSex: MRace: WHITEReg #: 76318-054
Date of Birth: 01/20/1953Facility: NYM
Encounter Date: 07/12/2019 13:10Provider: EMDUnit: Z05

Follow-up at Sick Call as Needed

Other:

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

Patient Education Topics:

Date InitiatedFormat
07/12/2019Counseling

Handout/Topic

Diagnosis

Provider

Copay Required: No

Outcome
Verbalizes
Understanding

Cosign Required: No

Telephone/Verbal Order:

Completed by

MD on 07/12/2019 14:20

Generated 07/12/2019 14:20 by

MD

Bureau of Prisons - NYM

Page 3 of 3

EFTA00110384

Bureau of Prisons Health Services Clinical Encounter

Inmate Name:EPSTEIN, JEFFREY EDWARD
Date of Birth:01/20/1953
Encounter Date:07/12/2019 13:10
Sex:MRace: WHITE
Provider:MDUnit: Z05

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

SUBJECTIVE:

Subjective:66 YR OLD WHITE MALE WITH HX OFHYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS800,NOW431.STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDEMEDS DUE TO THEIR GI SIDE EFFECTSHX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAPMACHINE.STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED.STATES THE FBI LOKELY HASL4-L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THELOWER EXTREMITIES.SURGICAL HX:NONEMENTAL 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): | Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology |

| :--- | :--- |

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

OBJECTIVE:

Exam:

General

Appearance

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

Generated 07/12/2019 14:20 by

Page 1 of 3

MD

Bureau of Prisons - NYM

EFTA00110385

Inmate Name:EPSTEIN, JEFFREY EDWARD
Date of Birth:01/20/1953
Encounter Date:07/12/2019 13:10
Reg #:76318-054
Facility:NYM
Unit:Z05

Exam:

Eyes

Description
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:
Rx#Medication
Magnesium Hydroxide Susp
Order Date
07/12/2019 13:10

Prescriber Order

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

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

AS DIRECTED Orally - daily x 6 day(s)

Disposition:

Generated 07/12/2019 14:20 by

Bureau of Prisons - NYM

Page 2 of 3

MD

EFTA00110386

Inmate Name: EPSTEIN, JEFFREY EDWARDSex: M Race: WHITEReg #: 76318-054
Date of Birth: 01/20/1953Facility: NYM
Encounter Date: 07/12/2019 13:10Unit: Z05

Follow-up at Sick Call as Needed

Other:

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

Patient Education Topics:

Date InitiatedFormat
07/12/2019Counseling
Handout/Topic
Diagnosis

Copay Required: No

Provider

Outcome
Verbalizes
Understanding

Cosign Required: No

Telephone/Verbal Order:

Completed by

MD on 07/12/2019 14:20

Generated 07/12/2019 14:20 by

MD

Page 3 of 3

Bureau of Prisons - NYM

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