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Jail record · July 12, 2019

Bureau of Prisons medical encounter record for Jeffrey Epstein, July 12, 2019

Bureau of Prisons chronic-care clinical encounter at MCC New York documenting Epstein's hypertriglyceridemia, sleep apnea, and back pain treatment, duplicated twice.Machine-written summary

EFTA00121320

Bureau of Prisons Health Services Clinical Encounter

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

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

SUBJECTIVE:

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 QUE 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

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

EFTA00121321

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

Exam:

Eyes

General

Yes: PERRLA, Extraocular Movements Intact

Pulmonary

Cardiovascular

Auscultation

Yes: Clear to Auscultation

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

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

Indication:Constipation, unspecified
MethylIPREDNISolone 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:

Generated 07/12/2019 14:20 by

Page 2 of 3

MD

Bureau of Prisons - NYM

EFTA00121322

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

Telephone/Verbal Order:

Cosign Required: No

Completed by

Outcome
Verbalizes
Understanding

Generated 07/12/2019 14:20 by

Page 3 of 3

MD

Bureau of Prisons - NYM

EFTA00121323

Bureau of Prisons Health Services Clinical Encounter

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

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

SUBJECTIVE:

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 QUE 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

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

MD

Page 1 of 3

Bureau of Prisons - NYM

EFTA00121324

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

Exam:

Eyes

General

Yes: PERRLA, Extraocular Movements Intact

Pulmonary

Cardiovascular

Auscultation

Yes: Clear to Auscultation

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

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

Indication:Constipation, unspecified
MethylIPREDNISolone 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:

Generated 07/12/2019 14:20 by

Page 2 of 3

MD

Bureau of Prisons - NYM

EFTA00121325

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

Telephone/Verbal Order:

Cosign Required: No

Completed by

Outcome
Verbalizes
Understanding

Generated 07/12/2019 14:20 by

Page 3 of 3

MD

Bureau of Prisons - NYM

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Retrieved from https://epstein-index.org/documents/ds9-efta00121320/.