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

EFTA00134737¶

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: 07/28/2019 20:25	Provider: RN	Unit: H01

Nursing - Follow up encounter performed at Health Services.¶

SUBJECTIVE:
COMPLAINT 1	Provider:	RN
Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies)
Subjective:	Inmate seen for F/U after returning from attorney conference offers no new complaints or worsening S/S stats "My R hand still has pins and needles sometimes" No change in appearance from previous exam.
Pain:	No

Date	Time	Rate Per Minute	Location	Rhythm	Provider
07/28/2019	20:28	81			RN

Date	Time	Rate Per Minute	Provider
07/28/2019	20:28 NYM	14	RN

Date	Time	Value	Location	Position	Cuff Size	Provider
07/28/2019	20:28 NYM	157/91

SaO2:
Date	Time	Value(%)	Air	Provider
07/28/2019	20:28 NYM	98		RN

Affect¶

Yes: Cooperative¶

Appearance¶

Yes: Appears Well, Alert and Oriented x 3¶

Nutrition¶

Yes: Within Normal Limits¶

Skin¶

General¶

Yes: Within Normal Limits, Dry, Skin Intact¶

ASSESSMENT:¶

No Significant Findings/No Apparent Distress¶

PLAN:¶

Disposition:¶

To be Evaluated by Provider¶

Generated 07/28/2019 20:30 by RN¶

Bureau of Prisons - NYM¶

Page 1 of 2¶

SDNY_00000994¶

| EFTA_00000203 | | :--- | :--- |¶

This is a simple text representation of a table with two columns. The first column contains the label “EFTA_00000203”, and the second column contains the corresponding data. No formatting or special characters are present.¶

EFTA00134738¶

Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/28/2019 20:25¶

Follow-up in 12-24 Hours¶

Patient Education Topics: Date Initiated Format: Counseling Handout/Topic: Plan of Care Provider: H01 Outcome: Verbalizes Understanding¶

Copay Required: No Cosign Required: Yes Telephone/Verbal Order: No Completed by: RN on 07/28/2019 20:30 Requested to be cosigned by: Cosign documentation will be displayed on the following page.¶

Generated 07/28/2019 20:30 by RN Bureau of Prisons - NYM¶

EFTA00134739¶

Bureau of Prisons Health Services Cosign/Review¶

Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Encounter Date: 07/28/2019 20:25 Provider: RN Reg #: 76318-054 Race: WHITE Facility: NYM¶

Cosigned by on 07/28/2019 20:50.¶

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	Provider: RN	Facility: NYM
Encounter Date: 07/28/2019 06:51		Unit: H01

Nursing - Triage Note encounter performed at Health Services.¶

SUBJECTIVE:¶

COMPLAINT 1	Provider:	RN
Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies)
Subjective:	"I woke up and I had no control over my Right arm for a few minutes it was just doing what it wanted to do"
Pain:	No

OBJECTIVE:¶

Pulse:¶

Date	Time	Rate Per Minute	Location	Rhythm	Provider
07/28/2019	06:57	82			RN

Respirations:¶

Date	Time	Rate Per Minute	Provider
07/28/2019	06:57 NYM	14	RN

Blood Pressure:¶

Date	Time	Value	Location	Position	Cuff Size	Provider
07/28/2019	06:57 NYM	138/80

Exam:¶

General¶

Affect¶

Yes: Cooperative¶

Appearance¶

Yes: Appears Well, Alert and Oriented x 3¶

Skin¶

General¶

Yes: Within Normal Limits, Dry, Skin Intact¶

Head¶

General¶

Yes: Symmetry of Motor Function, Atraumatic/Normocephalic¶

No: Facial Asymmetry, Battle’s Sign, Raccoon Eyes, Deformity¶

General¶

Yes: , Extraocular Movements Intact¶

Eyes¶

Face¶

Bureau of Prisons - NYM¶

Page 1 of 3¶

SDNY_00000997¶

EFTA_00000206¶

EFTA00134741¶

Inmate Name: EPSTEIN, JEFFREY EDWARD	Reg #: 76318-054
Date of Birth: 01/20/1953	Facility: NYM
Encounter Date: 07/28/2019 06:51	Unit: H01

Exam: No: Ecchymosis, Numbness, Swelling, Periorbital Edema¶

Neck¶

General Yes: Abrasion(s)¶

Pulmonary¶

Observation/Inspection Yes: Within Normal Limits No: Respiratory Distress, Tachypnea, Hyperventilation¶

Cardiovascular¶

Observation Yes: Normal Rate¶

Musculoskeletal¶

Shoulder Yes: Full Range of Motion R, Symmetric R No: Swelling R, Inflammation R¶

Humerus Yes: Within Normal Limits R¶

Elbow Yes: Normal Exam R, Full Range of Motion R, Non-Tender on Palpation R¶

Radius / Ulna Yes: Normal Exam R, Full Range of Motion R¶

Wrist/Hand/Fingers Yes: Full Range of Motion R, Non-Tender on Palpation R, Swelling R No: Inflammation R, Ecchymosis R, Erythema R, Tenderness R, Laceration(s) R, Abrasion(s) R, Contusion(s) R¶

ROS Comments¶

Received Inmate AAOX3 in no acute distress, speaking in full sentenced ambulating independently C/O Right arm numbness after waking up from “sleeping on my side” that has since subsided. Inmate interviewed in payo obs through the slot. V/S noted WNL, RR even and unlabored, no neurological deficits noted, no facial droop slur, which or dysphagia, Inmate with Full ROM to all extremities with 4/4 strength bilaterally, slight swelling noted to the palms when compared to left, no edema, erythema or ecchymosis noted. Denies any pain numbness or tingling. Denies any Chest pain, Headache, Dizziness, SOB or Blurred vision. Eyes MD on Call notif. evaluate intubation or cage if S/S persist.¶

ASSESSMENT:¶

Alteration in comfort¶

PLAN:¶

Disposition:¶

Position:¶

Follow-up at Sick Call as Needed¶

Notify Medical Duty Officer¶

Patient Education Topics:¶

| Date Initiated | Format |¶

| :--- | :--- |¶

| 07/28/2019 | Counseling |¶

Generated 07/28/2019 07:22 by¶

Handout/Topic¶

Plan of Care¶

RN¶

Bureau of Prisons - NYM¶

Provider¶

Columbo, Joseph¶

Outcome¶

Verbalizes¶

Understanding¶

Page 2 of 3¶

SDNY_00000998¶

EFTA_00000207¶

EFTA00134742¶

Date Initiated Format	Handout/Topic	Provider	Outcome
Copay Required: No	Cosign Required: Yes
Telephone/Verbal Order: No	RN on 07/28/2019 07:22
Requested to be cosigned by	Cosign documentation will be displayed on the following page.

Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM¶

Page 3 of 3 SDNY_00000999 EFTA_0000208¶

Bureau of Prisons Health Services Cosign/Review¶

Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Encounter Date: 07/28/2019 08:51 Provider: RN Reg #: 76318-054 Race: WHITE Facility: NYM¶

Cosigned by on 07/28/2019 20:51.¶