EFTA00138995


# 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:

## <table><tr><td>COMPLAINT</td><td>1</td><td>Provider:</td></tr></table>

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 FINE.

Pain: Not Applicable

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

## OBJECTIVE:

# Pulse:

| Date | Time | Rate Per Minute | Location | Rhythm | Provider |
| :---: | :---: | :---: | :---: | :---: | :---: |
| 07/30/2019 | 13:02 | 94 | | | MD |
| 07/30/2019 | 09:40 | 88 | Via Machine | | MD |
| 07/30/2019 | 09:30 | 87 | Via Machine | | MD |

# Respirations:

| Date | Time | Rate Per Minute | Provider |
| :---: | :---: | :---: | :---: |
| 07/30/2019 | 09:30 NYM | 12 | MD |

# 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 | | 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



SDNY_00017359
Page 1 of 3


EFTA00138996

<table border="1"><tr><td>Inmate Name:</td><td>EPSTEIN, JEFFREY EDWARD</td></tr><tr><td>Date of Birth:</td><td>01/20/1953</td></tr><tr><td>Encounter Date:</td><td>07/30/2019 11:12</td></tr></table>

## Exam:

## General

## Affect

## Appearance

## ASSESSMENT:

<table border="1"><tr><td>Body mass index(BMI)27.0-27.9, adult,Z6827-Current</td></tr><tr><td>Constipation,unspecified,K5900-Current</td></tr><tr><td>Essential(primary)hypertension,I10-Current-BYHX.</td></tr><tr><td>Hyperlipidemia,unspecified,E785-Current</td></tr><tr><td>Low back pain,M545-Current</td></tr><tr><td>Neuralgia and neuritis,unspecified,M792-Current</td></tr><tr><td>Prediabetes,R7303-Current</td></tr><tr><td>Sleep apnea,G4730-Current</td></tr></table>

## PLAN:

## New Medication Orders:

Generated 07/30/2019 14:05 by



SDNY_00017360

Page 2 of 3



MD

Bureau of Prisons - NYM

EFTA00138997

<table><thead><tr><th>Inmate Name:</th><th>EPSTEIN, JEFFREY EDWARD</th><th>Sex:</th><th>M Race:</th><th>WHITE</th><th>Reg #:</th><th>76318-054</th></tr></thead><tbody><tr><td>Date of Birth:</td><td>01/20/1953</td><td colspan="3">Provider:</td><td>Facility:</td><td>NYM</td></tr><tr><td>Encounter Date:</td><td>07/30/2019 11:12</td><td colspan="3">MD</td><td>Unit:</td><td>Z01</td></tr><tr><td colspan="7"><strong>New Medication Orders:</strong></td></tr><tr><td rowspan="4">Rx#</td><td>Medication</td><td colspan="3">Order Date</td><td colspan="2">Prescriber Order</td></tr><tr><td>Magnesium Hydroxide Susp conc 800 MG/5ML</td><td colspan="3">07/30/2019 11:12</td><td colspan="2">10 CC Orally - Two Times a Day PRN x 90 day(s)</td></tr><tr><td>Indication: Constipation, unspecified</td><td colspan="3"></td><td colspan="2">SLIDING SCALE Subcutaneously - Two Times a Day x 7 day(s) Pill Line Only</td></tr><tr><td>INsulin REG - Human</td><td colspan="3">07/30/2019 11:12</td><td colspan="2"></td></tr><tr><td colspan="7"><strong>Renew Medication Orders:</strong></td></tr><tr><td rowspan="2">Rx#</td><td>Medication</td><td colspan="3">Order Date</td><td colspan="2">Prescriber Order</td></tr><tr><td>methylIPREDONI Solene 4 MG Tab (21 count Pack)</td><td colspan="3">07/30/2019 11:12</td><td colspan="2">Take the tablet by mouth as directed x 6 day(s)</td></tr><tr><td colspan="7"><strong>New Laboratory Requests:</strong></td></tr><tr><td>Details</td><td>Frequency</td><td colspan="3">Due Date</td><td colspan="2">Priority</td></tr><tr><td>Lab Tests - Short List-General-CBC w/diff</td><td>One Time</td><td colspan="3">08/01/2019 00:00</td><td colspan="2">Routine</td></tr><tr><td>Lab Tests-P-PSA, Total</td><td></td><td colspan="3"></td><td colspan="2"></td></tr><tr><td>Lab Tests-U-Uric Acid</td><td></td><td colspan="3"></td><td colspan="2"></td></tr><tr><td>Lab Tests - Short List-General-Comprehensive Metabolic Profile (CMP)</td><td></td><td colspan="3"></td><td colspan="2"></td></tr><tr><td>Lab Tests-U-Urinalysis w/Reflex to Microscopic</td><td></td><td colspan="3"></td><td colspan="2"></td></tr><tr><td colspan="7"><strong>New Radiology Request Orders:</strong></td></tr><tr><td>Details</td><td>Frequency</td><td colspan="3">Due Date</td><td colspan="2">Priority</td></tr><tr><td>General Radiology-Spine / Cervical-General</td><td>One Time</td><td colspan="3">08/29/2019</td><td colspan="2">Routine</td></tr><tr><td colspan="7">Specific reason(s) for request (Complaints and findings):<br>66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUIMBRESS FOR 2-3 MINUTES 3 DAYS AGO. PLEASE PERFORM C SPINE SERIES</td></tr><tr><td colspan="7">Disposition:<br>Follow-up at Sick Call as Needed</td></tr><tr><td colspan="7">Patient Education Topics:</td></tr><tr><td>Date Initiated</td><td>Format</td><td>Handout/Topic</td><td colspan="2">Provider</td><td colspan="2">Outcome</td></tr><tr><td>07/30/2019</td><td>Counseling</td><td>Access to Care</td><td colspan="2"></td><td colspan="2">Verbalizes Understandin</td></tr><tr><td>07/30/2019</td><td>Counseling</td><td>Plan of Care</td><td colspan="2"></td><td colspan="2">Verbalizes Understandin</td></tr></tbody></table>



<table><tr><td>Copay Required: No</td><td>Cosign Required: No</td></tr><tr><td>Telephone/Verbal Order: No</td><td></td></tr><tr><td>Completed by</td><td>MD on 07/30/2019 14:05</td></tr></table>

Generated 07/30/2019 14:05 by

MD



SDNY_0001361
Page 3 of 3


Bureau of Prisons - NYM

EFTA00138998

# 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:

## <table><tr><td>COMPLAINT</td><td>1</td><td>Provider:</td></tr></table>

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 FINE.

Pain: Not Applicable

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

## OBJECTIVE:

## Pulse:

## Respirations:

## Blood Pressure:



SaO2:


## Weight:

Generated 07/30/2019 14:05 by



SDNY_00017362
Page 1 of 3


EFTA00138999

Inmate Name: EPSTEIN, JEFFREY EDWARD

Date of Birth: 01/20/1953

Encounter Date: 07/30/2019 11:12

## Exam:

## General

## Affect

## Appearance

## ASSESSMENT:

<table border="1"><tr><td>Body mass index(BMI)27.0-27.9, adult,Z6827-Current</td></tr><tr><td>Constipation,unspecified,K5900-Current</td></tr><tr><td>Essential(primary)hypertension,I10-Current-BYHX.</td></tr><tr><td>Hyperlipidemia,unspecified,E785-Current</td></tr><tr><td>Low back pain,M545-Current</td></tr><tr><td>Neuralgia and neuritis,unspecified,M792-Current</td></tr><tr><td>Prediabetes,R7303-Current</td></tr><tr><td>Sleep apnea,G4730-Current</td></tr></table>

## PLAN:

## New Medication Orders:

Generated 07/30/2019 14:05 by



SDNY_00017363

Page 2 of 3



MD

Bureau of Prisons - NYM

EFTA00139000

<table><thead><tr><th>Inmate Name:</th><th colspan="3">EPSTEIN, JEFFREY EDWARD</th><th>Reg #:</th><th>76318-054</th></tr><tr><th>Date of Birth:</th><td>01/20/1953</td><th>Sex:</td><td>M Race: WHITE</th><th>Facility:</th><td>NYM</th></tr><tr><th>Encounter Date:</th><td>07/30/2019 11:12</td><th>Provider:</td><td>MD</th><th>Unit:</th><td>Z01</th></tr></thead><tbody><tr><td colspan="6">New Medication Orders:</td></tr><tr><td rowspan="4">Rx#</td><td>Medication</td><td colspan="2">Order Date</td><td colspan="2">Prescriber Order</td></tr><tr><td>Magnesium Hydroxide Susp conc 800 MG/5ML</td><td colspan="2">07/30/2019 11:12</td><td colspan="2">10 CC Orally - Two Times a Day PRN x 90 day(s)</td></tr><tr><td>Indication: Constipation, unspecified</td><td colspan="2"></td><td colspan="2"></td></tr><tr><td>INsulin REG - Human</td><td colspan="2">07/30/2019 11:12</td><td colspan="2">SLIDING SCALE Subcutaneously - Two Times a Day x 7 day(s) Pill Line Only</td></tr><tr><td colspan="6">Indication: Prediabetes</td></tr><tr><td colspan="6">Renew Medication Orders:</td></tr><tr><td rowspan="2">Rx#</td><td>Medication</td><td colspan="2">Order Date</td><td colspan="2">Prescriber Order</td></tr><tr><td>methylPREDN Solone 4 MG Tab (21 count Pack)</td><td colspan="2">07/30/2019 11:12</td><td colspan="2">Take the tablet by mouth as directed x 6 day(s)</td></tr><tr><td colspan="6">Indication: Neuraxis and neuritis, unspecified</td></tr><tr><td colspan="6">New Laboratory Requests:</td></tr><tr><td>Details</td><td>Frequency</td><td>Due Date</td><td>Priority</td><td></td><td></td></tr><tr><td>Lab Tests - Short List-General-CBC w/diff</td><td>One Time</td><td>08/01/2019 00:00</td><td>Routine</td><td></td><td></td></tr><tr><td>Lab Tests-P-PSA, Total</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Lab Tests-U-Uric Acid</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Lab Tests - Short List-General-Comprehensive Metabolic Profile (CMP)</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Lab Tests-U-Urinalysis w/Reflex to Microscopic</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="6">New Radiology Request Orders:</td></tr><tr><td>Details</td><td>Frequency</td><td>Due Date</td><td>Priority</td><td></td><td></td></tr><tr><td>General Radiology-Spine / Cervical-General</td><td>One Time</td><td>08/29/2019</td><td>Routine</td><td></td><td></td></tr><tr><td colspan="6">Specific reason(s) for request (Complaints and findings):<br>66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUIMBNESS FOR 2-3 MINUTES 3 DAYS AGO. PLEASE PERFORM C SPINE SERIES</td></tr><tr><td colspan="6">Disposition:<br>Follow-up at Sick Call as Needed</td></tr><tr><td colspan="6">Patient Education Topics:</td></tr><tr><td>Date Initiated</td><td>Format</td><td>Handout/Topic</td><td>Provider</td><td colspan="2">Outcome</td></tr><tr><td>07/30/2019</td><td>Counseling</td><td>Access to Care</td><td></td><td colspan="2">Verbalizes Understanding</td></tr><tr><td>07/30/2019</td><td>Counseling</td><td>Plan of Care</td><td></td><td colspan="2">Verbalizes Understanding</td></tr></tbody></table>



<table><tr><td>Copay Required: No</td><td>Cosign Required: No</td></tr><tr><td>Telephone/Verbal Order: No</td><td></td></tr><tr><td>Completed by</td><td>MD on 07/30/2019 14:05</td></tr></table>

Generated 07/30/2019 14:05 by

MD



SDNY_00017364
Page 3 of 3


Bureau of Prisons - NYM