BOP medical encounter record for Jeffrey Epstein at MCC New York, July 30, 2019

EFTA00132701¶

Bureau of Prisons Health Services Clinical Encounter¶

Inmate Name: EPSTEIN, JEFFREY EDWARD	Sex: M Race: WHITE	Reg #: 76318-054
Date of Birth: 01/20/1953	Facility: NYM
Encounter Date: 07/30/2019 11:12	Unit: Z01

Chronic Care - Chronic Care Clinic encounter performed at Health Services.¶

SUBJECTIVE:¶

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 PINE

Pain:

Not Applicable

¶

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

OBJECTIVE:¶

Pulse:¶

Respirations:¶

Blood Pressure:¶

Date	Time	Value	Location	Position	Cuff Size	Provider
07/30/2019	13:02 NYM	114/84	Left Arm	Standing		MD
07/30/2019	09:40 NYM	125/60	Right Arm	Standing		Robert MD
07/30/2019	09:30 NYM	108/86	Left Arm	Sitting		MD

SaO2:¶

Date	Time	Value(%)	Air	Provider
07/30/2019	09:30 NYM	98	Room Air	MD

Weight:¶

Date	Time	Lbs	Kg	Waist Circum.	Provider

Generated 07/30/2019 14:05 by¶

Page 1 of 3¶

EFTA00132702¶

| Inmate Name: | EPSTEIN, JEFFREY EDWARD |¶

| :--- | :--- |¶

| Date of Birth: | 01/20/1953 |¶

| Encounter Date: | 07/30/2019 11:12 |¶

Sex:	M	Race:	WHITE
Provider:			MD

Reg #:	76318-054
Facility:	NYM
Unit:	Z01

Date	Time	Lbs	Kg	Waist Circum.	Provider
07/30/2019	09:30 NYM	194.2	88.1		MD

Exam:¶

General¶

Affect¶

Appearance¶

ASSESSMENT:¶

Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current

Constipation, unspecified, K5900 - Current

Essential (primary) hypertension, I10 - 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:
Rx#	Medication

Order Date¶

Prescriber Order¶

Generated 07/30/2019 14:05 by¶

MD¶

Page 2 of 3¶

Bureau of Prisons - NYM¶

EFTA00132703¶

Inmate Name: EPSTEIN, JEFFREY EDWARD	Sex: M	Race: WHITE	Reg #: 76318-054
Date of Birth: 01/20/1953	Provider:	MD	Facility: NYM
Encounter Date: 07/30/2019 11:12			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¶

Rx#	Medication	Order Date	Prescriber Order
121836-NYM	methylIPREDNISolone 4 MG Tab (21 count Pack)	07/30/2019 11:12	Take the tablet by mouth as directed x 6 day(s)
Indication: Neuralgia and neuritis, unspecified

Details	Frequency	End Date	Due Date	Priority
General Radiology-Spine / Cervical-General	One Time		08/29/2019	Routine

66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUIMBNESS FOR 2-3 MINUTES 3 DAYS AGO.¶

PLEASE PERFORM C SPINE SERIES¶

Disposition:¶

Follow-up at Sick Call as Needed¶

Patient Education Topics:¶

Date Initiated	Format	Handout/Topic
07/30/2019	Counseling	Access to Care

Plan of Care¶

Copay Required: No

Cosign Required: No

Telephone/Verbal Order: No¶

Generated 07/30/2019 14:05 by¶

Page 3 of 3¶

MD¶

Bureau of Prisons - NYM¶