| Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/09/2019 12:35 | Sex:
Provider: | | Race: WHITE | Reg #:
Facility:
Unit: | NYM
HO | 76318-054 | | ------------------------------ | ------------------------------------------------------------------------- | ----------------- | --- | ----------- | ---------------------------- | --------- | --------- | | Thorax: | | | | | | | | | Contour Normal:Yes | | | | | | | | | | Increased AP Diameter: No | | | | | | | | | Asymmetrical Expansion:No | | | | | | | | Lungs Clear: Yes | | | | | | | | | Wheezes: No | | | | | | | | | Crackles:No | | | | | | | | | Rhonchl: No | | | | | | | | | Rates: No | Accessory Muscle Use: No | | | | | | | | Comments: | | | | | | | | | | | | | | | | | | Spine: | | | | | | | | | Deformity: No | | | | | | | | | Full ROM:Yes | | | | | | | | | Tenderness:No | | | | | | | | | Comments: | | | | | | | | | Cardiovascular: | | | | | | | | | RRR: Yes | | | | | | | | | Normal S1/S2: Yos | | | | | | | | | Murmurs: No | | | | | | | | | Carotid Bruits:No | | | | | | | | | JVD: No | | | | | | | | | Arteries: | Left
Right | | | | | | | | Radial:
Femoral: | | | | | | | | | Dorsalis Pedis: | | | | | | | | | Post. Tiblalls: | | | | | | | | | Comments: | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/09/201912:35 | Sex:
Provider: | M | Race: WHITE | Reg #:
Facility:
Unit• | 7 318-054
H 1 | | ------------------------------ | ------------------------------------------------------------------------ | ----------------- | ---- | ----------- | ---------------------------- | ---------------- | | Abdomen: | | | | | | | | Normal Contour:Yes | | | | | | | | Soap hold: No | | | | | | | | Obese: No | | | | | | | | Gravid: No | | | | | | | | Hernias: No | | | | | | | | Bruits: No | | | | | | | | Masses:No | | | | | | | | Scars: No | | | | | | | | Tenderness: No | | | | | | | | Organomogaly: No | | | | | | | | | Active Bowel Sounds: Yes | | | | | | | Comments: | | | | | | | | Extremities: | | | | | | | | Nails Clubbing: No | | | | | | | | Nails Cyanosis: No | | | | | | | | | Lowor Extremity Edema - Right: None | | | | | | | | Lower Extremity Edema - Loft: None | | | | | | | Atrophy: No | | | | | | | | Amputations: No | | | | | | | | Other Deformities: No | | | | | | | | Varicosities:No | | | | | | | | Calf Tondornoss:No | | | | | | | | Pulse Deficit: No | | | | | | | | | Right | | 6€8 | | | | | Strength: | | | | | | | | Arm: | | | | | | | | Leg: | | | | | | | | Full ROM: | Right | | kelt | | | | | Arm: | Yes | | Yes | | | | | Leg: | Yes | | Yes | | | | | Comments: | | | | | | | | | | | | | | | | | | | | | | | | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/09/2019 12:35 | Sex:
Provider. | Race: WHITE
M | Reg #:
Facility:
Unit: | 76 18-054
1 | | ------------------------------ | ------------------------------------------------------------------------- | ----------------- | ----------------------- | ---------------------------- | -------------- | | Reflexes: | | | | | | | | Hight | | | | | | Biceps: | | | | | | | Patellar: | | | | | | | Brachloradialis: | | | | | | | Achilles: | | | | | | | Sensation: | | | | | | | Vibratory: Yes | | | | | | | Pin Prick: Yes | Light Touch: Yes | | | | | | Commonts: | | | | | | | | | | | | | | GU: | | | | | | | Chaperoned By: | | | | | | | Rectum: Not Done | | | | | | | Comments: Refused. | | | | | | | Male Genitalia: Not Done | | | | | | | Comments: Refused. | | | | | | | Skin: | | | | | | | Normal:Yes | | | | | | | Rash: No | | | | | | | Redness:No | | | | | | | | Abnormal Pigmentation: No
Abnormal Lesions/Growths: No | | | | | | Comments: | | | | | | | Lymphatics: | | | | | | | Adenopathy: No | | | | | | | Comments: | | | | | | | | Potential Items For Follow-up: | | | | | | them | | | | | | | Travel Outside US | | | | | | | | Other Infectious Disease History | | | | | | Rectum Not Done | | | | | | | | Male Genitalia Not Done | | | | | | | PPD Administration Not Performed | | | | | | Comments: | Patient has a history of constipation. | | | | | | Generated 07109/2019 13:03 by | | | Bureau of Patens - NY M | | Psgs12 at 13 | | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/09/2019 12:35 | Sex:
Provider: | HITE | Reg ft
Facility:
Unit: | 76318-054
NYM
1101 | | ------------------------------ | ---------------------------------------------------------------------------------------------------------------------------------- | -------------------- | ------------------------------ | ---------------------------- | ------------------------------- | | Health Problem | Cleared For Food Services: Yes
Health Problems Newly Identified During This Encounter.
Constipation, unspecified - Current - | | | | | | Now Medication Orders:
Rx# | Me ication
Bisacodyla. Tablet | | Order Date
07/09/2019 12:35 | prescriber Order
day(s) | 5 mg Orally at bedtime PRN x 10 | | | Indication: Constipation, unspecified | | | | | | Disposition: | Follow-up at Sick Call as Needed | | | | | | | Instructed Inmate how to obtain medical, dental, and mental health care. | | | | | | Copay Required: No | No
TolophoneNerbal Order:
on 07/09/2019 13:03 | Cosign Required: Yes | | | | | Completed by | Requested to be cosigned by
Cosign documentation will be displayed on the following page. | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Generated 07/09/'1018 13:03 by | | &OM of Prisons - NYM | | | Pogo 13 of 13 | | Prisons
of
Bureau
Services
Health
Cosign/Review | | | | | | | -------------------------------------------------------------- | ------------------------------------------------------------------------- | -------------------- | ---------------------- | ---------------------------- | ------------------------- | | Inmate Name:
Date of Birth: | EPSTEIN. JEFFREY EDWARD
01/20/1953
Encounter Date: 07/09/2019 12:35 | Sex:
Provider: | M | Reg #:
Race:
Facility: | 76818-054
WHITE
N M | | Cosigned by | | on 07/11/2019 22:41. | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Bureau of Bosons • NYM | | | ### Bureau of Prisons Health Services Inmate Local Hospital Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD | | ed.
SENSITIVE BUT UNCLASSIFIED — This information is confidential and must be appropriately safeguard | | | | ---------------------------------------------------------------------------------------------- | -------------------------------------------------------------------------------------------------------- | --- | --- | | Transfer To: | Transfer Date: 08/1012019 | | | | Health Problems | | | | | Health Problem | Status | | | | HypedlpIdernia, unspecified
HYPERTRIGLYCERIDEMIA | Current | | | | Sleep apnea | Current | | | | Essential (primary) hypertension
BY HX. | Current | | | | Constipation, unspecified | Current | | | | Low back pain | Current | | | | Neuralgia and neuritis, unspecified | Current | | | | | Current | | | | No Diagnosis
Prediabetes | Current | | | | | Current | | | | Injury, unspecified
R./O self inflicted injuries.
Body mass index (BMI) 27.0-27.9, adult | Current | | | Medications: All medications to be continued until evaluated by a physician unless otherwise in laded. Bolded drugs required for transport. Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take cne capsule (100 MG) by mouth twice d ily for 30 days Docusate Sodium 100 MG Cap Exp: 01/22/2020 SIG: Take one capsule (100 MG) twice daily by uth with plenty of water Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML Exp: 10/28/2019 SIG: shake well take 10mi by ouch twice daily AS NEEDED Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by mouth i with food OTCs: Listing of all known OTCs this Inmate Is currently taking. | None | | | | | | | | ------------------------------------------ | ------------------------- | ------------------ | ----------------------- | ------------------------ | ------------------ | ----------- | | Pending Appointments | | | | | | | | Date | lime | Activity | | | Provider | | | 07/24/2019 | 00:00 | Clinical Encounter | | | Optometrist | | | 01/07/2020 | 00:00 | Chronic Care Visit | | | Mid-Level Provider | | | 07/01/2020 | 00:00 | Chronic Care Visit | | | Physician 01 | | | 07/09/2020 | 00:00 | PPD Administration | | | Nurse | | | Pending Non-Medication Orders: | | | | | | | | Order | Order Date | Frequency | Duration Details | | | | | EKG | 07/06/2019 | One Time | | 66 y/o male | | | | Focal Occult Blood | 07/06/2019 | One Time | | 3 different stools | | | | TB Clearance: Yes | | | | | | | | | Last PPD Date: 07/09/2019 | | | Induration: 0mm | | | | Last Chest X-Ray Date: | | | | Results: | | | | | TB Treatment | | | Sx free for 30 days: Yes | | | | TB Follow-up Recommended: No | | | | | | | | Sickle Cell:
Sickle Cell Trait/Disease: | No | | | | | | | Generated 08/1012019 07:00 by | | | Bureau of Prisons - NYM | | | Page 1 of 2 | | Reg #: 76318-054 | Inmate Name: EPSTEIN, JEFFREY EDWARD | | | | | | | | | ----------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------ | ----------------------- | --------- | ---- | ------------------------ | ----- | ----------- | --- | | SENSITIVE BUT UNCLASSIFIED — This information Is confidential and must be appropriately saleguard6d. | | | | | | | | | | Limitations/Restrictions/Diets:
Cell: lower bunk — 10/0912019
Cleared for Food Service: Yes
Other diet restrictions: FISH ALLERGIES. -- 07/30/2020 | | | | | | | | | | Comments: | | | | | | | | | | Allergies
No Known Allergies | | | | | | | | | | Devices / Equipment
•Pap | | | | | | | | | | Travel:
Direct Travel: No
Travel Restrictions: None
UNIVERSAL PRECAUTIONS OBSERVED WHEN TRANSPORTING ANY INMATE: | | | | | | | | | | Transfer From Institution: NEW YORK MCC
Address 1:
Address 2: | 150 PARK ROW | | | | Phone Number: 6468366300 | | | | | City/State/Zp: | NEW YORK, New York 10007 | | | | | | | | | NameMtle of Person Completing Form: | | | | | | Date. | 08/10/2019 | | | EPSTEIN, JEFFREY EDWARD
Inmate Name: | | Rog #: | 76318-054 | DOB: | 01/20/1953 | Sex: | M | | | | | | | | | | | | | Generated 03/10/2019 07:00 by | | Bureau of Prisons - NYM | | | | | Page 2 of 2 | | ### Bureau of Prisons Health Services ![](_page_7_Figure_1.jpeg) ![](_page_8_Figure_0.jpeg) ![](_page_9_Figure_0.jpeg) Generaled 08/10/2019 11:02 by Bureau or Prisons • NYM Pigs 3d 3 # Bureau of Prisons Health Services # PPDs ![](_page_10_Figure_2.jpeg) Generated 08/10/2019 11:02 by illnOP/IDC Bureau of Prisons - NYM Page 1 of I | 31
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#:
Reg | 07107/2019
76318-054 | | Stop
Date:
Inmate | 08/10/2019
EPSTEIN,
Name: | EDWARD
JEFFREY | | | --------------------------- | ----------------------- | ------------- | ----------------------- | ------------------------------- | ----------------- | --------------------------------------------------------------------------------------------- | | Pelk61Egulnment | | Start
Date | Stop
Date | Returned
Pate | Obtained
From | Comments | | "Pap
07/30/2019 | EST
14:05 | 07/30/2019 | | | Personal | CPAP
ONE
SYSTEM
RESPIRONICS
PHILIPS
MACHINE.
P11312813B1ED.
SERIAL
#. | Total: 1 Generated C8110/2019 11:02 by MilOP/IDC Bureau of Prisons - NYM Paco 1 of 1 # Bureau of Prisons Health Services | Pain Management | | | | | | | | ------------------------------------ | ------------------------------------------------- | --- | --- | --- | --- | --- | | Begin Date: 07/07/2019 | End Date:
08/10/2019 | | | | | | | Reg #:
76318-054 | Inmate Name: EPSTEIN, JEFFREY EDWARD | | | | | | | Intervention
gate | Ere Post
Provider
t,ocation
Pain Quality | | | | | | | 07/12/2019 13:25
MEDROL DOSE PACK | 5
Back-Middle
Shooting | | | | | | | Orig Entered: 07/12/2019 13:28 EST | | | | | | | | | Prisons
of
Bureau
Services
Health
Request
Diet
Modified | | | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | | Types of Diets: | | | | Clear Liquid
Low Fat
Mechanical Soft
Low Cholesterol
Low TrIglyceride
Renal
Full Liquid
\_
Sodium Controlled
Snack
Dlabetic
Calorie Controlled
FISH ALLERGIES.
X Other: | Exp Date:
Exp Date:
Exp Date:
Exp Date:
Exp Date:
Exp Date:
Exp Date:
Exp Date:
Exp Dato:
Exp Date:
Exp Date:
Exp Date: 07/3012020 | | | Comments:
EPSTEIN, JEFFREY EDWARD
Inmate Name | Health Service Staff
7/30/2019
76318-054
Date
Rog# | | | of
Prisons
Bureau
Health
Services
Allergies
Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054 | | | | | | | ---------------------------------------------------------------------------------------------------------------------- | -------------------- | ------------------------ | -------- | --- | --- | | Allergy
No Known Allergies
Orig Entered:
Total: 1 | 07/06/2019 21:40 EST | Pate Noted
07/06/2019 | Reaction | | | | | | | | | | | | | | | | | # Bureau of Prisons Health Services Patient Education Assessments & Topics ![](_page_17_Figure_1.jpeg) | 4
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ta | | | | | # Bureau of Prisons Health Services | Blood Glucose | | | | | | | | ------------- | ---------------------------------------------------------------------------- | ---------------------------------- | ----------- | -------------------------------------------------- | --- | --- | | Reg #: | Begin Date: 07/07/2019
76318-054 | | End Date: | 08/10/2019
Inmate Namo: EPSTEIN, JEFFREY EDWARD | | | | | (Reference Range: Random or Fasting 70 - 100, 2 hour post-prandlal 70 - 140) | | | | | | | fain | Emu | Value | TVDO | Comments. | | | | 08/04/2019 | 08:30 NYM 156 | | Non-Fasting | | | | | | | Orig Entered: 08/04/2019 09:08 EST | | | | | | 08102/2019 | 06:30 NYM 97 | | Non-Fasting | | | | | | | Orig Entered: 08/02/2019 08:16 EST | | | | | | 08/01/2019 | 06:30 NYM 103 | | Non-Fasting | | | | | | | Orig Entered: 08/01/2019 09:00 EST | | | | | | 07/31/2019 | 06:15 NYM 108 | | Non-Fasting | | | | | | | Orig Entered: 07/31/2019 08:36 EST | | | | | | Total: 4 | | | | | | | # Bureau of Prisons Health Services ## Health Problems | Reg #: 76318-054 | inmate Name: EPSTEIN, JEFFREY EDWARD | | | | | | --------------------------------------------------------------------------- | ------------------------------------ | ------------- | ----- | -------------------- | ----------- | | De cnDtiort | | &la Code Tvoe | rata | Diag. Date
Status | Status Date | | | Current | | | | | | Hyperlipidemia, unspecified
07/12/2019 13:48 EST
HYPERTRIGLYCERIDEMIA | | ICD-10 | E785 | 07/12/2019 Current | | | Sleep apnea
07/12/2019 13:56 EST | | ICD-10 | G4730 | 07/12/2019 Current | | | Essential (primary) hypertension
07/30/2019 13:13 EST
BY HX. | | ICD-10 | 110 | 07/30/2019 Current | | | Constipation, unspecified
07/09/2019 12:58 EST | | ICD-10 | K5900 | 07/09/2019 Current | | | Low back pain
07/12/2019 13:30 EST | | ICD-10 | M545 | 07/12/2019 Current | | | Neuralgia and neuritis, unspecified
07/12/2019 13:30 EST | | ICD-10 | M792 | 07/12/2019 Current | | | No Diagnosis
07/09/2019 10:28 EST | | I DSM-IV | No Dx | 07/09/2019 Current | | | Prediabetes
07/30/2019 13:26 EST | | ICD-10 | R7303 | 07/30/2019 Current | | | Injury, unspecified
07/23/2019 09:04 EST
R/O self inflicted R'EI
M | | ICD-10 | T1490 | 07/23/2019 Current | | | mass Index (BMI) 27.0-27.9, adult
Body | | | | | | | 07/30/2019 13:14 EST | | ICD-10 | Z6827 | 67,315/2019 Current | | Total: 10 Generated 08/10201911:02 by EllOPADC Bureau of Prisons - NYM Page 1 ol 1 # Bureau of Prisons Health Services Clinical Encounter | Health Services | | | | | | | | | | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | -------------------------------------------------------------------- | ------------------------------ | --- | --- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | -------------------------------- | ---------------- | --- | | Clinical Encounter | | | | | | | | | | EPSTEIN, JEFFREY EDWARD
Inmate Name:
01/20/1953
Date of Birth:
Encounter Date: 07/12/2019 13:10 | | Sex:
Provider: | | | Race: WHITE | Reg #:
Facility: NYM
Unit: | 76318-054
Z05 | | | Chronic Care - 14 Day Physician Eval encounter performed at Health Services. | | | | | | | | | | SUBJECTIVE: | | | | | | | | | | COMPLAINT 1 | Provider: | | | | | | | | | Chief Complaint: ENDO/LIPID | | | | | | | | | | Subjective:
66 YR OL
HYPERT
800 ,
MEDS
HX OF O
MACHINE.
STATES THE
L4 - L5 SEVERE
LOWER EXTREMI | HITE MALE WITH HX OF
S.
SURGICAL HX: NONE
MENTAL HEALTH HX: | EIR GI SIDE EFFECTS.
LY HAS | | | CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS
STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE
UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP
HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED.
SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE | | | | | 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. Oyspneic, Appears in Pain. Writhing in Pain, Pale. Pallor, Cyanotic. Diaphoretic. Disheveled. Unkempt. Acutely III #### Nutrition No: Appears Obese Generated 07/12/2019 1420 by Bureau of Prisons - NYM Page 1 of 3 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Reg #: 76318-054 Facility: NYM | | Encounter Date: 07/12/2019 13:10 | Provider: MM.= | 205
Unit: | | ----------------------------- | --------------------------------------------------- | ------------------------------ | ---------------------------- | | Exam: | | | | | Eyes | | | | | General | | | | | | Yes: PERRLA, Extraocular Movements Intact | | | | Pulmonary | | | | | | Auscultation | | | | | Yes: Clear to Auscultation | | | | Cardiovascular | | | | | | Auscultation | | | | | Yes: Regular Rat | Rhythm (RRR), Normal S1 and S2 | | | Abdomen | No: M/R/G | | | | | Auscultation | | | | | Yes: Normo-Active B | | | | | Palpation | | | | | Yes: Within Normal Limits | | | | Musculoskeletal | | | | | | Tibia / Fibula | | | | | No: Edema | | | | Back | | | | | | Yes: Tenderness | | | | Neurologic | | 11°) | | | | Cranial Nerves (CN) | | | | | n Normal Limits
ithi
Yes: W | | | | | Motor System-General | | | | | Yes: Normal Exam | % lt
O | | | ASSESSMENT: | | | | | | Constipation, unspecified, K5900 - Current | | | | | Hyperlipidemia, unspecified, E785 - Current | | >d | | | Low back pain, M545 - Current | | #
er | | | Neuralgia and neuritis, unspecified, M792 - Current | | | | | Sleep apnea, O4730 - Current | | | | PLAN: | | | | | New Medication Orders: | | | | | Rx | Medication | Order Date | Prescriber Order | | | Magnesium Hydroxide Susp | 07/12/2019 13:10 | 30 CC Orally - Two Times a | | | | | Day PRN x 2 day(s) | | | Indication: Constipation, unspecified | | | | | MethyiPREDNISolone Tab 4 MG ( Dose | 07/12/2019 13:10 | AS DIRECTED Orally - daily x | | | Pack 21 tab) | | 6 day(s) | | | Indication: Neuralgia and neuritis, unspecified | | | | Disposition: | | | | | Genornied 07/12/2019 14:20 by | | Bureau of Prisons • NYM | | | | | | Page 2 ol 3 | | EPSTEIN, JEFFREY EDWARD
Inmate Name:
Date of Birth:
01/20/1953
Encounter Date: 07/12/2019 13:10 | M
Sex:
Provider: | Race: WHITE | Reg #:
Facility: NYM
Unit: | 76318 4054
Z05 | | | ----------------------------------------------------------------------------------------------------------- | ----------------------- | ----------- | -------------------------------- | ----------------- | --------------------------- | | Follow-up at Sick Call as Needed | | | | | | | Other: | | | | | | | WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP. | | | | | | | Patient Education Topics: | | | | | | | pate Initiated
Format | Handout/Tonic | | Provider | | Outcome | | Counseling
07/12/2019 | Diagnosis | | | | Verbalizes
Understanding | | Copay Required:No
TelephoneNerbal Order: | Cosign Required: No | | | | | | Completed by | n 07/12/2019 14:20 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Generated 07/1212019 14:20 by | Bureau of Prisons - NYM | | | | Page 3 of 3 | | | | | | | | # Bureau of Prisons Health Services | | | Health Services
Clinical Encounter | | | | | | | ----------------------------------------------------------------------------------------------------------- | -------------------------------------------- | ------------------------------------- | --- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | -------------------------------- | ----------------------------------------------------------- | --- | | EPSTEIN, JEFFREY EDWARD
Inmate Name:
Date of Birth:
01/20/1953
Encounter Date: 07/12/2019 13:10 | | Sex:
Provider: | M | Race: WHITE | Reg #:
Facility: NYM
Unit: | 76318-054
205 | | | Chronic Care - 14 Day Physician Eval encounter performed at Health Services. | | | | | | | | | SUBJECTIVE: | | | | | | | | | COMPLAINT 1 | Provider: | | | | | | | | Chief Complaint: ENDO/LIPID | | | | | | | | | HYPERT
800 .
MEDS
HX OF O
MACHINE.
STATES THE -
L4 - L5 SEVERE
LOWER EXTREMI
Pain: | 1?
SURGICAL HX: NONE
MENTAL HEALTH HX: | EIR GI SIDE EFFECTS.
Y HAS | | . STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE
UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP
HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED.
SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE | | CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRILL WAS | | | 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 III #### Nutrition No: Appears Obese Genera:NI 07/12/2019 14:20 by-Bureau of Prisons • NYM Page 1 of 3 | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/12/2019 13:10 | Sex:
Provider: | M | Race: WHITE | Reg 1,1:
Facility: NYM
Unit: | 76318-054
Z05 | | | ------------------------------ | ------------------------------------------------------------------------- | ----------------- | ---------- | ---------------- | ---------------------------------- | --------------------------------------------------- | --- | | Exam: | | | | | | | | | Eyes | | | | | | | | | General | | | | | | | | | | Yes: PERRLA, Extraocular Movements Intact | | | | | | | | Pulmonary | | | | | | | | | | Auscultation
Yes: Clear to Auscultation | | | | | | | | Cardiovascular | | | | | | | | | | Auscultation | | | | | | | | | Yes: Regular Rat
Rhythm (RRR), Normal S1 and S2 | | | | | | | | | No: M/R/G | | | | | | | | Abdomen | | | | | | | | | | Auscultation | | | | | | | | | Yes: Normo-Active B | | | | | | | | | 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: | | | | | | | | | Medication | | Order Data | | | Prescriber Order | | | | Magnesium Hydroxide
Susp | | | 07/12/2019 13:10 | | 30 CC Orally - Two Times
a
Day PRN x 2 day(s) | | | | | | | | | | | AS DIRECTED Orally - daily x 6 day(s) Disposition: Generated 07/127201914:20 by Bureau of Prisons-NYM Page 2 of 3 Pack 21 tab) 07/12/2019 13:10 Indication: Constipation, unspecified MethylPREDNISolone Tab 4 MG ( Dose Indication: Neuralgia and neuritis, unspecified | EPSTEIN, JEFFREY EDWARD
Inmate Name:
01/20/1953
Date of Birth:
Encounter Date: 07/12/2019 13:10 | M
Sex:
Provider: | Reg It:
Facility: NYM
Race: WHITE
Unit: | 76318-054
Z05 | | ----------------------------------------------------------------------------------------------------------- | ------------------------------------------------------ | ------------------------------------------------ | -------------------------------------- | | Follow-up at Sick Call as Needed | | | | | Other: | | | | | | WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP. | | | | Patient Education Topics: | | | | | Date Initiated
Format
Counseling
07/12/2019 | Handout/Toeic
Diagnosis | Pr_oytdel | Outcome
Verbalizes
Understanding | | Copay Required: No
i
TelephoneNerbal Order:
Completed by | Cosign Required: No
07/12/2019 14:20 | | | | | | | | | | | | | | | | | | | | | | | | | | el, | | | | | | | | | | | | | | | | | | | | | | | Generated 07/12/2019 14:20 by | Bureau of Prisons • NYM | | Page 3 of 3 | | | | | Bureau of Prisons
Health Services
See Amendment | | | | ------------------------------ | ------------------------------------------------------------------------- | ---- | ----------------------------------------------------- | ---------------------------- | ------------------------- | | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/14/2019 17:36 | Sex: | M | Reg #:
Race:
Facility: | 76318-054
WHITE
NYM | | | Amendment made to this note by | | on 07/14/2019 18:11. | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Bureau of Prisers - NYM #### Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Note Date: 07/12/2019 09:06 Provider: Reg ft: 7E318.054 Facility: Unit Z05 Admin Note - Orders encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider. PATIENT REQUESTED TO HAVE A COLACE RX, INSTEAD OF TEH BISACODYL FOR CONSTIPATION. Now Medication Orders: Hy& Medication Order Date Dccusate Sodium Capsule 07/12/2019 09:06 Indication: Constipation, unspecified Discontinued Medication Orders: Medication Order Date 121757-NYM Bisacodyi. 5 MG TAB 07/12/2019 09:06 Discontinue Type: When Pharmacy Processes Discontinue Reason:discontinue Indication: Copay Required: No TelephoneNerbal Order: No Completed by Cosign Required: No on 07/12/2019 09:10 TAKE ONE 1 - Two Times MG CAP Orally Day x 30 day(s) Take one tabl t (5 MG) by mouth at bedtime A NEEDED for 10 days Page 1 of 1 # Bureau of Prisons Health Services Clinical Encounter - Administrative Note | Inmate Name:
Date of Birth:
Note Date: | EPSTEIN, JEFFREY EDWARD
01/20/1953
07/07/2019 00:17 | | Sex:
Provider. ISIS | | | Reg #:
Unit | NYM
E06 | 76318-054 | | ---------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------- | ----------------------- | --------- | ---------------------------- | -------------- | ---------- | ----------- | | Administrative Notes: | Cosign Note - Intake Cosign encounter performed at Health Services.
ADMINISTRATIVE NOTE 1
MED CL:1
NO CCC APPT. | Provider: | | | | | | | | | Discontinued Laboratory Requests: | | | | | | | | | Details
Lab Testst-CBC w/diff
Lab Tests-L-Lipid Profile
(CMP) | Lab Tests-H-Hemoglobin AlC
Lab TeststComptehensive Metabolic Profile
Lab Tests-U-Urinalysis vdReffex to Microscopic
Additional Information:
6410 male, elevated BP
Labs requested to bo reviewed by: | | Frequency
One Time | | Due Date
08/05/2019 00:00 | | Priority | &wilt\* | | New Laboratory Requests: | | | | | | | | | | Detail%
Lab Tests-H-HIV 1/2
Lab Tests-R-RPR | Chronic Care Clinics-Diabetic-CBC wkliff
Chronic Care Clinics-Diabetic-Lipid Profile
Chronic Care Cfinics-Diabetic-Hemoglobin
Chronic Care Clinics-Diabetic-Comprehensive | | Emumnset
One Time | | Rue Date
07/25/2019 00:00 | | | RobUne | | Metabolic Profile (CMP) | New Radiology Request Orders: | | | | | | | | | Details | | | Frequency | grid Date | pue Date | | | ipriority | | | General Radiology-Chest-2 Views | | One Time | | | 07/25/2019 | | Routine | | | Specific reason(s) for request (Complaints and findings): | | | | | | | | | | 66 YR OLD MALE WITH NO MINX, REFERRED FOR ROUITNE CXR. | | | | | | | | | Copay Required: No
TelephoneNerbal Order:
Completed by | No | on 07/07/2019 00:30 | Cosign Required: No | | | | | | | Generated 07/07/2019 0030 by | | | Bureau of Prisons - NYM | | | | | Page 1 of 1 | # Bureau of Prisons Health Services History & Physical | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/09/2019 12:35 | | Sex:
Provider | Race: WHITE
M | Reg #:
Facility:
Unit | 76318-054
NYM
H01 | | ------------------------------ | ------------------------------------------------------------------------- | ------------------------- | ---------------- | ---------------- | --------------------------- | ----------------------- | | Seizures: | | Denied | | | | | | Diabetes: | | Denied | | | | | | Cardiovascular: | | Denied | | | | | | CVA: | | Denied | | | | | | Hypertension: | | Denied | | | | | | Respiratory: | | Denied | | | | | | Sickle Cell Anemia: | | Denied | | | | | | Carcinoma/Lymphoma: | | Denied | | | | | | Allergies: | | Denied | | | | | | Tuberculosis: | | | | | | | | | Hx of Previous Disease: No | | | | | | | Blood-tinged Sputum: | No | | | | | | | Night Sweats: | No | | | | | | | Weight Loss:No | | | | | | | | Fever: No | | | | | | | | Cough:No | | | | | | | | Comments: | | | | | | | | Infectious Disease Risk | Factors: | | | | | | | IV Drug Use: No | | | | | | | | IV Drug Use Needles: | | | | | | | | Sexual Partner IV | Drug Use:
No | | | | | | | Sexual Partner IV Drug | Use Needles: | | | | | | | Female Sexual | Partners (Last | 5 Yrs): 10+ | | | | | | Male Sexual Partners | (Last 5 Yrs): | 0 | | | | | | Condom Use: | Sometimes | | | | | | | Sexual Contact | With HIV+ Individual: | No | | | | | | Blood Product | Transfusion: No | | | | | | | Travel Outside US: Yes | | | | | | | | Tattoos: No | | | | | | | | Comments: Born | in US
High school diploma
Banker
Traveled to Parts | x 3 weeks up until arrest | | | | | | | No tattoos | | | | | | Generated 07/09/2019 13:03 by Bureau of Prisons - NYM Pale lot 13 | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953 | | Sex: | M | Race: WHITE | Reg #:
Facility. | NYM
H01 | 76318-054 | | ------------------------------ | ---------------------------------------------------------------- | -------- | --------- | --- | ----------- | ------------------- | ---------- | --------- | | | Encounter Datoi: 07/09/2019 12:35 | | Provider. | | | Unit: | | | | HIV History: | | | | | | | | | | When Tested: | | 2019 | | | | | | | | Test Result: | | Negative | | | | | | | | When Diagnosed AIDS: | | | | | | | | | | Last CD4: | | | | | | | | | | Comments: | | | | | | | | | | Hepatitis: | | Denied | | | | | | | | Other Infectious Diseases: | | | | | | | | | | Syphilis: | | No | | | | | | | | Syphilis Last Treatment: | | N/A | | | | | | | | Genital Warts: | | No | | | | | | | | Chlamydia: | | Yes | | | | | | | | Gonorrhea: | | No | | | | | | | | Herpes: | | No | | | | | | | | Chicken Pox: | | Yes | | | | | | | | Other: | | No | | | | | | | | | Comments: Chlamydia in 2015, treated
Chicken pox in childhood | | | | | | | | | Abuse History: Denied | | | | | | | | | | Physical: No | | | | | | | | | | Emotional: No | | | | | | | | | | Sexual: No | | | | | | | | | | Comments: Denies | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/09/2019 12:35 | Sex:
Provider: | M | Race: WHITE | Reg #:
Facility:
Unit: | 76318-054
NYM
I-101 | | ------------------------------ | ------------------------------------------------------------------------- | ----------------- | --- | ----------- | ---------------------------- | ------------------------- | | Mental Health: | | | | | | | | | Level of Consciousness: Alen | and Oriented | | | | | | | Psychomotor Activity: Normal | | | | | | | | General Appearance:Normal | | | | | | | Behavior: Cooperative | | | | | | | | Mood: Appropriate | to Content | | | | | | | Thought Process: Goal | Directed | | | | | | | | Thought Content: Normal | | | | | | | | Hx of Mental Health Treatment: | None | | | | | | Hx of Head Injury: None | | | | | | | | | Current Mental Health Treatment: | No | | | | | | | Current Mental Health Complaint: | No | | | | | | | Hx of Loss of Consciousness:
No | | | | | | | Hx of Hearing Voices: | No | | | | | | | Past History of Suicide | Attempt: No | | | | | | | Current Suicide Ideation: | No | | | | | | | Suicide Prevention | Initiated:No | | | | | | | Comments: | | | | | | | | Substance Use History: | Denied | | | | | | | Current Painful Condition: | Denied | | | | | | | Other Health issues: | | | | | | | | | Current Medical Conditions: | | | | | | | Other Current Treatments: | | | | | | | | Pregnant: | N/A | | | | | | | | Dental Condition: | | | | | | Generated 07/0912019 13:03 by Bumau of Prisons - NYM Page 3 of 13 | Observations:
Draining Skin Lesions: No
Signs of Lice: No
Signs of Scabios: No
Signs of Recent Trauma: No
Recent Tattoos: No
Noodle Marks: No
Signs of Rash: No
Open Sores: No
Wounds: No
Body Deformities: No
Tremors: No
Sweating: No
Comments: | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/09/2019 12:35 | Sex:
Provider: | ITE | Reg ti:
Facility:
Unit | 7.318-054 | | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------ | ------------------------------------------------------------------------- | ----------------- | --- | ---------------------------- | --------- | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/09/2019 12:35 | Sex:
Provider | M | Race: WHITE | Reg/S.
Facility:
Unit: | 7931&064
NYM
H01 | | ------------------------------ | ----------------------------------------------------------------------------------- | ----------------------- | --- | ----------- | ---------------------------- | ---------------------- | | Immunizations: | | | | | | | | | Hepatitis A and B (TwinRx) Series Administration: History Unknown, Not Administered | | | | | | | | Documented Date: 07/09/2019 12:51 EST | | | | | | | | Immunization Date: | | | | | | | Provider:MEM | ) | | | | | | | Location: | | | | | | | | Drug Mfg: | | | | | | | | Lot Number | | | | | | | | Dosage: | | | | | | | | Route: | | | | | | | | Exp Dt: | | | | | | | | Comments: | | | | | | | | | Measles/Mumps/Rubella Series Administration: History Unknown, Not Administered | | | | | | | | Documented Date: 07/09/2019 12:51 EST | | | | | | | | Immunization Date: | | | | | | | Provider: | | | | | | | | Location: | | | | | | | | Drug Mfg: | | | | | | | | Lot Number | | | | | | | | Dosage: | | | | | | | | Route: | | | | | | | | Exp Dt: | | | | | | | | Comments: | | | | | | | | | Smallpox Series Administration: History Unknown, Not Administered | | | | | | | | Documented Date: 07/09/2019 12:51 EST | | | | | | | Immunization Date: | | | | | | | | Provider: | | | | | | | | Location: | | | | | | | | Drug Mfg: | | | | | | | | Lot Number: | | | | | | | | Dosage: | | | | | | | | Routo: | | | | | | | | Exp Dt: | | | | | | | | Comments: | | | | | | | | | Tetanus Administration: History Unknown, Not Administered | | | | | | | | Documented Date: 07/09/2019 12:51 EST | | | | | | | Ginetales107109/2019 13.03 by | | Bureau of Prisons - NYM | | | | Page 5 of 13 | | Inmate Name:
Date of Birth:
Encounter Date: 07/09/2019 12:35 | 01/20/1953 | EPSTEIN. JEFFREY EDWARD | Sex: | Provider: | WHITE | Reg #:
Facility:
Unit: | A318-054
NYM
901 | | ------------------------------------------------------------------ | -------------------------------- | ----------------------- | ---------------------- | --------------------------------- | ------------------ | ---------------------------- | ---------------------- | | | Immunization Date: | | | | | | | | Provider: | | | | | | | | | Location: | | | | | | | | | Drug Mfg: | | | | | | | | | Lot Number: | | | | | | | | | Dosage: | | | | | | | | | Route: | | | | | | | | | Exp Dt: | | | | | | | | | Comments: | | | | | | | | | | Varicella Series Administration: | | | History Unknown, Not Administered | | | | | | Documontod Date: | 07/09/2019 12:51 EST | | | | | | | | Immunization Date: | | | | | | | | Provider: | | | | | | | | | Location: | | | | | | | | | Drug Mfg: | | | | | | | | | Lot Number: | | | | | | | | | Dosage: | | | | | | | | | Route: | | | | | | | | | Exp Dt | | | | | | | | | Comments: | | | | | | | | | Temperature: | | | | | | | | | Da_tft
07/09/2019 | hale
12:49 NYM | Fahrenheit
97.3 | | csisina Location
36.3 Oral | Provider | | | | Pulse: | | | | | | | | | Pate
07/09/2019 12:49 | EMS | Rate Per Minute | 82 | Location
Via Machine | phvthro
Regular | Provider | | | Respirations: | | | | | | | | | 07/09/2019 | Time
12:49 NYM | | 16 | RaoPer Minute Provider | | | | | Blood Pressure: | | | | | | | | | pie
07/09/2019 12:49 NYM | T me | Value
117/66 | Location.
Right Arm | Position | Cuff ska | Provider | | | SaO2: | | | | Sitting | Adult-regular | | | | ate
07/09/2019 | Time
12:49 NYM | Valuer/el Air | 97 Room Air | | Provider | | | | Height | | | | | | | | | Rale
07/09/2019 12:49 | Time
NYM | tad=
70.0 | fin
177.8 | Provider | | | | | Generated 07/09/2019 13:03 by | | | | Bureau of Plisans - NYM | | | P10116c1 13 | | Inmate Name:
Date of Birth:
Encounter Date: 07/09/2019 12:35 | 01/20/1953 | EPSTEIN, JEFFREY EDWARD | | Sex:
Provider: | | HITE | Reg #:
Facility:
Unit: | 76318-054
NYM
H01 | | --------------------------------------------------------------------------------------------------------------------------------------- | ------------ | -------------------------------------- | ---- | -------------------------------------------- | -------------------- | ---- | ------------------------------ | ----------------------- | | Pain
Weight:
pita | Time
Time | She%
1,ba | | ci
Kg Waist Circum. | Provider
Pmvider | | | | | 07/09/2019 | 12:49 NYM | 194.4 | 88.2 | | | | | | | Prosthetic Devices/Equipment: Denied
Tobacco Usage: Denied | | | | | | | | | | General Social History: | | | | | | | | | | Foreign Travel:
Born in USA:
Country of Birth: USA | Yes | | | | | | | | | Patient Education Assessments: | | | | | | | | | | Date
07/09/2019 | Ed Yrs | Occupation
12 Banker | | Learns Best By
Speaking/Listening English | Primary I am:mane | | Farriers to Education.
None | | | Family History - Father. | | | | | | | | | | Age at Death: 74
Significant Illnesses:
Diabetes | | Causo of Death: Diabetes complications | | | | | | | | Heart Disease | | | | | | | | | | Comments: | | | | | | | | | | Family History - Mother: | | | | | | | | | | Age at Death: 81
Cause of Death: Kidney Failure
Significant illnesses:
Heart Disease
Comments:
Family History - Sibling: | | | | | | | | | | Number of Siblings: I | | | | | | | | | | Significant Illnesses: | | | | | | | | | | Comments:
Past Hospitalization: | | | | | | | | | | Reason | | | | location | | | When | | | Acute Appendicitis
Complications: None
Comments: | | | | | Mount Sinai Hospital | | 1990 | | | Head: | | | | | | | | | | Normal:
Yes
Comments: | | | | | | | | | | Generated 07/09/2019 13:03 by | | | | Bureau of Prisons • NYM | | | | Page 7 of 13 | | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/09/2019 12:35 | | Sex:
Provider: | M | Race: WHITE | Reg 8:
Facility:
Unit | ;318-054
1 | | ------------------------------ | ------------------------------------------------------------------------- | ---------------------------- | ----------------- | --- | --------------- | --------------------------- | ------------- | | Eyes: | | | | | | | | | EOMI: Yes | | | | | | | | | Icterus:No | | | | | | | | | | Conjunctival Inflammation:
No | | | | | | | | Pupils PERRLA: Yes | | | | | | | | | Pupil Size Rt: | | | | | | | | | Pupil Size Lt: | | | | | | | | | Pupils Comments: | | | | | | | | | Fundi Vessels Nicking: | No | | | | | | | | | Fundi Vessels Discs Flat:Yes | | | | | | | | Fundi Vessels Grounds | Fundi Vessels Discs Sharp Margins:Yes | Abnormal: No | | | | | | | Eyes Comments: | | | | | | | | | Vision Screen | 07/09/2019 12:52 | | | | | | | | Blindness: | | | | | With Corrective | | | | | Distance Vision: OD: 100 | OS: 70 | | | | | | | | | | OU: | | OD: | OS | | | Near Vision: | OD: | OS: | OU: | | OD: | OS: | | | Ishihara Color Test: | | | | | | | | | Tonometry: | L: | R: | | | | | | | Comments: Needs | | evaluation with optometrist. | | | | | | | Ears: | | | | | | | | | | | | | | | | | | Right Ear: Canal
Left Ear: | patent | | | | | | | | | Canal patent | | | | | | | | Ears Comments: | | | | | | | | | Nose: | | | | | | | | | Nares Patent: Yes | | | | | | | | | Septum Midlino:yes | | | | | | | | | Septum Intact: Yes | | | | | | | | | Drainage/Discharge: No | | | | | | | | | Polyps: No | | | | | | | | | Nose Comments: | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Geteratod 07/09/2019 13:03 by Bureau of Prisms - NYM Page 6 of 13 | Inmate Name:
Dale of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/09/2019 12:35 | Sex:
Provider | M | Race: WHITE | Reg #:
Facility:
Unit: | 76318-054
tsiYM | | ------------------------------------ | ------------------------------------------------------------------------- | ---------------- | --- | ----------- | ---------------------------- | ------------------ | | Mouth | | | | | | | | Lesions:No | | | | | | | | Oral/Buccal Mucosa:Yes | | | | | | | | Gums Normal: Yes | | | | | | | | Tonsils Present: Yes | | | | | | | | | Tonsils Normal: Yes | | | | | | | Pharynx: Normal Color | | | | | | | | Teeth Poor Dentition: No | | | | | | | | | Teeth Count:Mostly Present | | | | | | | Dentures:No
Mouth Comments: | | | | | | | | Cranial Nerves: | | | | | | | | Intact \[tall: Yes | | | | | | | | | Cranial Nerves Comments: | | | | | | | | | | | | | | | Neck: | | | | | | | | Full ROM:Yes | | | | | | | | Masses/Nodes: No
Trachea: Midline | | | | | | | | Thyroid: Normal Size | | | | | | | | Comments: | | | | | | | | Breasts: | | | | | | | | Normal: Yes | | | | | | | | Masses:No | | | | | | | | Tenderness: No | | | | | | | | Scars: No | | | | | | | | Dimpling:No
Nipple Discharge: No | | | | | | | | Nipple Retraction:No | | | | | | | | | Instructions for Self Breast Exam Given: No | | | | | | | Comments: | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | # Bureau of Prisons Health Services #### Vision Screens | Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054 | | | | | | | | | | | -------------------------------------------------------- | ----------------------- | ---------------------------------- | --- | --------- | ----------------------- | -------- | ---- | ----------- | --- | | Vision Screen on 07/09/2019 12:52 | | | | | | | | | | | Blindness: | | | | | | | | | | | OD: 20/100
Distance Vision: | | | | OS: 20/70 | | | OU: | | | | OD:
Near Vision: | | | | OS: | | | OU: | | | | With Corrective | | | | | | | | | | | | OD:
Distance Vision: | | | OS: | | | OU: | | | | Near Vision: | OD: | | | OS: | | | OU: | | | | Present Glasses - Distance | | | | | Retraction - Distance | | | | | | Sphere | Cylinder | Axis | Add | | Sphere | Cylinder | Axis | Add | | | R: | | | | | R: | | | | | | L: | | | | | L: | | | | | | Color Test: | | | | | | | | | | | R:
Tonometry: | | L: | | | | | | | | | Comments: | | Needs evaluation with optometrist. | | | | | | | | | Orig Entered: | | 07/09/2019 12:54 EST | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Generated 08/102019 11:02 by | | | | | Bureau of Prisons • NYM | | | Pape 1 of 1 | | # Bureau of Prisons Health Services Immunizations | | Begin Date: 07/07/2019 | | End Date: | 08/10/2019 | | | | | | ----------------------------------------------------------------- | ---------------------- | ---------------------------------- | ------------------------------- | ---------- | ------------------------------------ | --- | --------- | --- | | Reg #: | 78318-054 | | | | Inmate Name: EPSTEIN, JEFFREY EDWARD | | | | | immunization
Immunization Date
Hepatitis A and B (TwinRx) | | | Administered
History Unknown | I-A:cation | DtagEfg.
Dosage | Lai | Ex!) Date | | | Orig Entered: 07/091201912:51 EST
Measles/Mumps/Rubella Series | | | History Unknown | | | | | | | Orig Entered: 07/09/2019 12:51 EST
Smallpox Series | | History Unknown | | | | | | | | Tetanus | | Orig Entered: 07/09/2019 12:51 EST | History Unknown | | | | | | | Varicella Series | | Orig Entered: 07/09/201912:51 EST | History Unknown | | | | | | | Total: 5 | | Orig Entered: 07/09/201912:51 EST | | | | | | | # Bureau of Prisons Health Services | Medical | Duty | Status | | --------- | ------ | -------- | | --------- | ------ | -------- | | | Status
Duty
Medical | | | | ---------------------------------------------------------------------------------------------------------------------------------------------------------- | --------------------------------------------------------------------------------------------------- | ---------------------------------------------------------- | ----------- | | Reg #: 76318-054 | Inmate Name: EPSTEIN, JEFFREY EDWARD | | | | :-I
Housing:Staat4
confined to the living quarters except \_meals
on complete bed rest:
single cell
cell on first floor
X cell:
other. | treatments
pill line
bathroom privileges only
airborne infection isolation
X lower bunk | Exp. Date:
Exp. Date:
Exp. Date:
Exp. Dale: | 10/09/2019 | | 0.-%141,11.Y:al.v.r. • •
all sports y -
\_upper body
1419!
w\*91"
•• cardraVascular exercise: \_running \_jogging \_walking \_softball
other. | •
-
\_lower body
stationary equipment
football \_basketball \_handball | :
Exp. Date:
Exp. Date:
Exp., Date:
Exp. Date: | | | 413alarrajtertielartflaWth ilialfk | | | | | Equipment
I
-Pap
PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE.
SERIAL St: P1131281381ED. | End Date
Start Date
07/30/2919 | | Return Date | | RIfsakIWZMITIMMLORM
I15"
Yes
Cleared for Food Service: | q.4. '";;;;Lt | | | | X No Restrictions
Comments: N/A | | 07/30/2019 | | | Health Services Staff
EPSTEIN, JEFFREY EDWARD
Inmate Name: | Quarters:
76318.054
Reg #: | Date
Z04 | | | ALL EXPIRATION DATES ARE AT 24:00
. • | | | | | | | | | | | | | | | Generated 013/10/2019 11:02 by | Bureau of Nuns • NYM | | Page 1 oil | | Prisons
of
Bureau | | | | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | ---------------------------------------------------- | ---------- | | Services
Health | | | | Status
Medical
Duty
Inmate Name: EPSTEIN. JEFFREY EDWARD
76318-054
Reg ft | | | | treatments
pill line
confined to the living quarters except \_meals
\_bathroom privileges only
on complete bed rest,/
,
airborne infection isolation
single cell X lower bunk
X cell:
cell on riot floor:,
other: | Exp. Date:
Exp. Date:
Exp. Date:
Exp. Date: | 10/09/2019 | | i.faaali:
piagistrictiAlArC;A:Z
g t
;-.
lirlita
Patiiii4
all sporia •:' .
'
—
\_lower body
weightlift
—
— . ? t
-i9.
softball
running \_jogging
walking
ascular exercise:
.ceonil
:-f,-
—
stationaryequipment
\_football \_basketball
handball
1:4. other: | Exp. Date:
Exp. Date:
Exp. Date:
Exp. Date: | | | WiliggaataTafrivin
inihaYeavroWlyinqielraThirrifiri, | | | | artilaraMaSiOgNarg
@Tr
-
Yes
Cleared for Food Service:
X No Restrictions
N/A
Comments: | 07/09/2019
Dale | | | Health Services Staff
Quarters:
76318-054 | Z04 | | | Reg a:
EPSTEIN, JEFFREY EDWARD.
Inmate Name:
ALL EXPIRATION DATES ARE AT 24:00
•
•
ors-
v e
e
.\`t.
St 6QY y
a
4O ,
.1149\* | | | | Bureau ol Prisons - NYM
Generated 08/10/2019 1102 by | | Page 1 oil | | | | | | | | | | Prisons
of
Bureau
Services
Health
Summary
Medication
Historical | | | | | | | | ------------------------------------------------------------------------------------ | ------------------------------------ | ---------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------- | ---------------------------- | --------------------------------------- | --- | | | | | | Begin Date: 07/07/2019 | End Date: Q8/10/2019 | | | Inmate: | Complex: NYM—NEW YORK MCC | EPSTEIN. JEFFREY EDWARD | Reg #: | 76318-054 | 04-206LAD
Quarter: | | | | | | Medications listed reflect prescribed medications from the begin dato to end date on this report. | | | | | | | Denied | | | | | | Allergies: | | | | | | | | | Active Prescriptions | | | | | | | | 5 MG TAB
Bisacodyl II | | | | | | | | | | Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10 days | | | | | Rx#: | 121757-NYM | Doctor. | | | 32days | | | | Start: 07/09/19 | Exp: 07/19/19 | D!C: 07/12/19 | Pharmacy Dispensings: 10 TAB | | | | | Dowsato Sodium 100 MG Cap | | | | | | | | | Take one capsule (100 MG) by mouth twice dail for 30 da s | | | | | | | 121823-NYM | Doctor. | | | | | | | Start: 07/12/19 | Exp: 08/11/19 | | | Pharmacy Dispensings: 60 CAP in 29 days | | | | Docusate Sodium 100 MG Cap | | | | | | | | | | Take one capsule (100 MG) twice daily by mouth with plenty of water | | | | | Rx#: | 122084-NYM | Doctor: | | | | | | | Start: 07/26/19 | Exp: 01/22/20 | | | Pharmacy Dispensings: 30 CAP in 15 days | | | | | | | | | | | | | Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML
shake well take 2 tablespoonful twice daily b mouth | | | | | | Rx#: | 121835-NYM | Doctor: | | | | | | | Start: 07/12/19 | Exp: 07/14/19 | | | Pharmacy Dispensings: 473 ML in 29 days | | | | | | | | | | | | | Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML | | | | | | | 122150-NYM | shake well take 10ml by mouth twice daily AS NEEDED
Doctor. | | | | | | | Start 07/30/19 | Exp: 10/28/19 | | | Pharmacy Dispensings: 473 ML in 11 days | | | | | | | | | | | | | methylPREDNISolone 4 MG Tab ( 21 count Pack) | | | | | | | Take the tablet by mouth as directed | | | | | | | Rx#: | 121836-NYM | Doctor. | | | | | | | Start: 07/12/19 | Exp: 07/18/19 | | | Pharmacy Dispensings: 21 tab in 29 days | | | | | methylPREDNISolone 4 MG Tab ( 21 count Pack) | | | | | | | Take the tablet by mouth as directed | | | | | | | Rx#: | 122149-NYM | Doctor: | | | | | | | Start: 07/30/19 | Exp: 08/05/19 | | | Pharmacy Dispensings: 21 tab in 11 days | | | | | | | | | | | | Generated 68/10/201911O2 by | | Bureau la!Priscns •NYM | | Page 1 of 2 | | | | | | | | | | | | | | | Begin Date: 07/07/2019 | End Date: 08/10/2019 | | ------- | ------------------------------------------------------------------------------------------------------------- | ------------------------------------------------------ | -------------------------------------------------------------------------------------- | ------------------------------------------------------- | ---------------------------------------- | | Inmate: | Complex: NYM—NEW YORK MCC | EPSTEIN, JEFFREY EDWARD | Reg #: | 76318-054 | 204-206LAD
Quarter: | | | Active Prescriptions
Omega 3 (Vascepa) 1 GM Capsule | Take two capsules (2 GM) twice daily b mouth with food | | | | | Rx#: | 121885-NYM
Start 07/17/19 | Doctor:
Exp: 01/13/20 | | | Pharmacy DIspensIngs: 180 Cap in 24 days | | Rx#: | Insulin Reg (10 ML) 100 UNITS/ML Inj
Inject regular Insulin subcutaneous)
122148-NYM
Start: 07/30/19 | Doctor.
Exp: 08/06/19 | er slidin scale: twice daily \*\*spill linem for 7 days "'pill line'"
: 07/31/19
D | | Pharmacy olspensIngs: 0 ML in 11 days | | | Insulin Reg (10 ML) 100 UNITS/ML Inj | Inject regular insulin subcutaneous | | sr-me: each morning for 7 days "'pill linen 'pill line— | | | Rx#: | 122160-NYM
Start: 07/31/19 | Doctor
Exp: 08/07/19 | | | Pharmacy Dlspensings: 0 ML in 10 days | | | | | | | | | | | | | | | # Bureau of Prisons Health Services Dental Health History Screen | Inmate Name:
01/20/1953
Date of Birth:
Encounter Date: 07/26/2019 07:54 | EPSTEIN, JEFFREY EDWARD | M
Sex:
Provider. | Race: | WHITE | Rag #:
redly: NYM
Unit | 7631
1101 | | | -------------------------------------------------------------------------------------------- | ----------------------- | ---------------------- | ----- | ---------------- | ---------------------------- | ------------ | --- | | | | | | | | | | | ASSESSMENTS:
Health Problems as of Dental Health History Encounter date: 07/26/2019 07:54 | | | | | | | | | Health Problems | | | | | | | | | Haaltbnahlara | | | | | Status | | | | Hypeilipidemia, unspedfted
HYPERTRIGLYCERIDEMIA | | | | | Current | | | | Sleep apnea | | | | | Current | | | | Constipation, unspecified | | | | | Current | | | | Low back pain | | | | | Current | | | | Neuralgia and neuritis, unspecified | | | | | Current
Current | | | | No Diagnosis
Injury, unspecified
R/O self inflicted injuries. | | | | | Current | | | | Medical History as of Dental Health History Encounter date: | | | | 07/26/2019 07:54 | | | | | Medical History: | | | | | | | | | Allergies: | Denied | | | | | | | | Seizures: | Denied | | | | | | | | Diabetes: | Denied | | | | | | | | Cardiovascular: | Denied | | | | | | | | CVA: | Denied | | | | | | | | Hypertension: | Denied | | | | | | | | Respiratory: | Denied | | | | | | | | Sickle Coll Anemia: | Denied | | | | | | | | Carcinoma/Lymphoma: | Denied | | | | | | | | HIV History: | | | | | | | | | When Tested: | 2019 | | | | | | | | Test Result: | Negative | | | | | | | | When Diagnosed AIDS: | | | | | | | | | Last CD4: | | | | | | | | | Comments: | | | | | | | | | Hepatitis: | Denied | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/26/2019 07:54 | M
Sex:
Provider. | | Reg It
Unit: | 76318-054
NYM
H01 | | | ------------------------------------------ | -------------------------------------------------------------------------------- | ---------------------- | --------------------- | --------------- | ----------------------- | ----------- | | Other Infectious Diseases: | | | | | | | | Syphilis: | No | | | | | | | | Syphilis Last Treatment:
WA | | | | | | | Genital Warts: | No | | | | | | | Chiamydia: | Yes | | | | | | | Gonorrhea: | No | | | | | | | Herpes: | No | | | | | | | Chicken Pox: | Yes | | | | | | | Other. | No | | | | | | | | Comments: Chiamydia In 2015, treated
Chicken pox In childhood | | | | | | | Other Health Issues: | | | | | | | | | Other Medical Conditions And Treatment: sleep apnea | | | | | | | | Current Medical Conditions: | | | | | | | | Other Current Treatments: | | | | | | | Pregnant N/A | | | | | | | | | Dental Observations as of Dental Health History Encounter date: 07/26/2019 07:54 | | | | | | | | History: | | | | | | | Alcohol: | | No | | | | | | Methamphetamine: | | No | | | | | | Tobacco products: | | No | | | | | | Other drugs: | | No
No | | | | | | Sensitive tooth: | | Yes | | | | | | Bleeding gums:
Food impaction: | | Yes | | | | | | Pain around ear: | | No | | | | | | Toothache: | | No | | | | | | Wear partial dentures: | | No | | | | | | | Unusual sounds while eating: | No | | | | | | Snoring: | | Yes | | | | | | | Blisters on lips or mouth: | No | | | | | | Clenching or grinding: | | Yes | | | | | | | Swelling or lumps in mouth/throat: | No | | | | | | Burning tongue: | | No | | | | | | Bad breath: | | No
No | | | | | | Decayed teeth: | | | | | | | | Loose teeth: | | No | | | | | | Wear dentures: | | No
No | | | | | | None: | | | | | | | | Comments:
Generated 07/26/2019 07.59 by | | | Buroau of Prisons NYM | | | Page 2 of 3 | | | | | | | | | | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/26/2019 07:54 | | Sex:
M
Provider. | Race: | WHITE | Reg ft:
Facility:
Unit: | 76318-054
NYM
H01 | | | ------------------------------ | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------- | ---------------------- | ----- | ---------------- | ----------------------------- | ----------------------- | --- | | | Cardiac Condition Requiring Prophylaxis: No | | | | | | | | | Prosthetic joint(s): | | No | | | | | | | | | Radiation history of head or neck: | No | | | | | | | | Excessive bleeding: | | No | | | | | | | | Bisphosphonates: | | No | | | | | | | | Comments: | | | | | | | | | | Medications: | Medications as of Dental Health History Encounter dato:
Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take one capsule (100 MG) by mouth twice daily for 30 days
Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by mouth with food
OTCs: Listing of all known OTCs this inmate Is currently taking. | | | | 07/26/2019 07:54 | | | | | | Instructed inmate how to obtain medical, dental, and mental health care. | | | | | | | | | Copay Requlred:No | TelephoneNerbal Order:
No | Cosign Required: No | | | | | | | | Completed by | | cn 07/26/2019 07.59 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | of
Bureau
Health
A&O
Dental | Prisons
Services
Exam | | | | ------------------------------------------ | ---------------------------------- | ---------------------------------------------------------------------------- | ------------------------------------------------------------- | --------------------------------------------------------------------------------------------------- | --------------------------- | -------------------- | | Inmate Name:
Date of Birth: | | EPSTEIN. JEFFREY EDWARD
01/20/1953
Encounter Date: 07/26/2019 07:47 | Sex: M
Provider. | Sam | Reg #:
Facility:
Unit | 6318-054
YM
01 | | Occlusion:
Oral Hygiene: Fair
CPITN: | Reviewed Health Status:
Class I | Yes | | | | | | 3 | 2 | 3 | | | | | | 3 | 2 | 3 | | | | | | Comments: | | Head 8, Neck/Soft Tissue within normal limits? | No
moderato to advanced upper posterior gingival recession | Hard and soft tissue examination performed and documented on BP618 form: Yes | | | | Decayed: | Missing: | Filled: | | | | | | 0 | 1 | 14 | | | | | | Comments: | | Lower anterior crowding
Approved for hygiene appointment and radiographs: | | Yes
Instructed inmate how to obtain routine and emergency dental care. Oral hygiene instructions | | Yes
Ivan: | | 07/26/2019 07:47. | | | | Dental A80 Screening Exam findings entered on EPSTEIN, JEFFREY EDWARD by | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Generated 07/28/2019 08:00 by | | Bureau of Prisons • NYM | | | Papist 1 | | Bureau
Dental | | | | | | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ----------------- | --- | ----------------------------- | ----------------------- | | EPSTEIN, JEFFREY EDWARD
Inmate Name:
01/20/1953
Date of Birth:
Encounter Date: 07/18/2019 13:48 | Sex:
Provider | | Reg ft:
Facility:
Unit: | 76318-054
NYM
205 | | Screening encounter at Dental Clinic.
Unavailable
Reason Not Done:
Comments: Patient has had several call outs for his Dental A 8 O screening but has not been escorted to
Cosign Required: No
Completed by IIIMMEIMIMon | 07/19/2019 13:49. | | | the dental clinic. | #### U.S. Medi I Prisons ![](_page_50_Picture_1.jpeg) | હ | | | | | | --- | --- | --- | --- | --- | | 6 | | | | | | | | | | •" Sensitive But Unclassified "" | | | ------------------------------------ | --------------------- | --------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --------------------------------------------- | -------------------------------- | --- | | | | MCC New York
Facility | Collected 07109/2019 13:34 | | | | Name EPSTEIN, JEFFREY | | Order Unl | Received 07/10/2019 10:44 | | | | Reg # 76318-054
DOB
01/20/1953 | | Provider | Reported 07/10/201914:46 | | | | Sex
M | | | 188191004
LIS ID | | | | | | | | | | | | | CHEMISTRY | | | | | | | 137 | 137-148 | mmoUL | | | Sodium | | 4.7 | 3.5-5.0 | mmot/L | | | Potassium | | | 99-114 | mmoUL | | | Chloride | | 99 | 22-30 | mmoUL | | | CO2 | | 27 | 7-22 | mg/dL | | | BUN | | 17 | 0.66.1.25 | mg/dL | | | Creatinlne | | 1.05 | | | | | eGFR (IDMS) | | >60 | | | | | | | GER units measured as mt./min/1.73 m^2. if African American multiply by 1.210.
A calculated GFR \<60 suggests chronic kidney disease d found over a 3 month period. | | | | | Calcium | | 9.8 | 8.5.10.9 | mg/dL | | | Glucose | | 102 | 70.110 | mg/dL | | | AST | H | 57 | 11-55 | U/L | | | ALT | | 62 | 11-66 | U/L | | | Alkaline Phosphatase | | 64 | 41-133 | U/L | | | Bilirubln, Total | | 1.1 | 0.2-1.3 | mg/dL | | | Total Protein | | 7.3 | 6.0-8.2 | g/dL | | | | | 4.4 | 3.6-5.1 | g/dL | | | Albumin | | 2.9 | 2.0-3.7 | g/dL | | | Globulin | | 1.50 | 1.00-2.30 | | | | Alb/Glob Ratio | | | 9.0-19.0 | | | | Anion Gap | | 10.2 | 5.0-30.0 | | | | BUN/Creat Ratio | | 16.1 | | | | | Cholesterol | H | 216 | \<200 | mg/dL | | | Triglycerides | H | 413 | 10-150
Therefore the LDL is not caloCated. | mg/dL | | | | | Calculation of LDL Is not appropriate for samples with a triglycende greater than 400 mg/dL | | | | | HDL Cholesterol | L | 31 | 40-60 | mg/dL | | | ChoUHDL Ratio | H | 6.9 | 0.0-4.0 | | | | | | HEMATOLOGY | | | | | WBC | | 7.6 | 4.3-11.1 | KM\_ | | | NRBC% | | 0.0 | | | | | RBC | | 5.42 | 4.46-5.78 | M/uL | | | | | 15.6 | 13.6-17.6 | g/dL | | | Hemoglobin
Hematocrit | | 47.8 | 40.2-51.4 | | | | MCV | | 88.2 | 82.5-96.5 | IL | | | MCH | | 28.8 | 27.1-34.9 | 13-9 | | | MCHC | L | 32.6 | 33.0-37.0 | g/dL | | | RDW-CV | | 12.8 | 12.0.14.0 | | | | Platelet | | 338 | 130-374 | K/uL | | | | | H=High HI=High Critical | A=Abnormal Al =Abnormal Critical | | | | FLAG LEGEND | L=Low LI=Low Critical | | Page 1 of | | | ### U.S. Med al Prisons ![](_page_51_Picture_1.jpeg) ![](_page_51_Picture_2.jpeg) ••• Sensitive But nclasstfled ••• | | Name EPSTEIN. JEFFREY | | | --- | --------------------- | --- | | | Reg # 76318-054 | | | DOB | 01/20/1953 | | | Sex | M | | Facility MCC New York Order Uniiii-547U Provider a Collected 07/09/2019 13:34 Received 07/1012019 10:44 Reported 07/10/201914:46 LIS ID 188191004 | | | HEMATOLOGY | | | | | --------------------------------------------------------------------------------------- | --------------- | -------------- | ----------------------- | ---------------------------------- | ------- | | MPV | | 10.4 | | 6.9-10.5 | IL | | Neutrophils % | | 583 | | | | | Therapeutic decision making should bo based on absolute values, rather than percentages | | | | | | | Lymphocytes % | | 25.0 | | | | | Monocytes % | | 11.1 | | | | | Eosinophils % | | 4.1 | | | | | Basophils % | | 0.8 | | | | | Immature Granulocytes % | | 0.3 | | 0.0-5.0 | K/uL | | Neutrophiis # | | 4.4 | | 1.9-6.7 | K/uL | | Lymphocytes # | | 1.9 | | 1.3-3.7 | KM. | | Monocytes # | | 0.8 | | 0.3-1.1 | K/uL | | Eosinophils # | | 0.3 | | 0.0-0.5 | K/uL | | Basophils # | | 0.1 | | 0.0-0.1 | 10"3/uL | | Immature Granulocytes # | | 0.02 | | 0.00-0.50 | | | | | HEMOGLOBIN A1C | | | | | Hemoglobin AIC | H | 6.3 | | \<5.7 | | | 5.7 - 8.4 tnaeased Risk
> 8.4 Diabetes | | | | | | | | | SEROLOGY | | | | | RPR | | Non-Reactive | | Non-Reactive | | | Results may be affected In patients with severely advanced immunosuppression. | | | | | | | L=Low
FLAG LEGEND | LI=Low Critical | | ht=High H=HIgh Critical | A=Abnorrnal Al =Abnotrnal Critical | | | Federal
Bureau of
Prisons | Medi
S
U | Prisons
I
I Sensitive But Unclassified\*\*\*
- | | | ------------------------------------------------------------------------- | ------------------------ | ---------------------------------------------------- | --- | | | | Collected 07/09/2019 13:34 | | | Name EPSTEIN, JEFFREY | MCC New York
Facility | Received 07/10/2019 10:44 | | | Reg ti 76318-054 | Order Unit E06-547U
• | Reported 07/10/2019 14:46 | | | 01/20/1953
DOB | Provider | 188191)04
LIS ID | | | M
Sex | | | | | | | | | | | HIV | | | | HIV 1/2
Screening test - See confirmatory testing for Reactive results | Negative | Negative | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | H=High H!=High Critical | A=Abnormal Al =Abnormal Critical | | | FLAG LEGEND | L=Low Lt=Low Critical | Page 3 of | | | | | | | | | | | of
Bureau | Prisons | | | | ------------------------------ | -------------------------------- | ------------------- | ------------- | ------------------ | --------- | --------- | | | | | Health | Services | | | | | | | Cosign/Review | | | | | | EPSTEIN, JEFFREY EDWARD | | | | Reg #: | 76318-054 | | Inmate Name:
Date of Birth: | 01/20/1953 | | Sex: | M | Race: | WHITE | | | Encounter Date: 07/10/2019 16:58 | | Provider. | Lab Result Receive | Facility: | NYM | | | | on 07/141201918:12. | | | | | | Cosigned by | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Bureau of Prisons • NYM SEP CS U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24.2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental CO Won, and release the Buroau of Prisons and Its employees from any and all liability for respecting and f• owing my expressed wishes and directions. | Counseled by | 7-24-2019
Date | is Sign
a | Date | | --------------------------------- | ----------------- | ------------------ | ---- | | a\*\*
si
nature
of Witne s | Date | NYM -N EW YORK MCC | | # BP-A0618 A&O DENTAL EXAMINATION (initial Clinical Dental Findings) FEDERAL BUREAU " PRISONS JUN 16 U.S. DEPARTMENT OF JUSTICE | | | Occlusion: | | | | ---------------------------------------------------------- | ---------------------------------------------------------------------------- | ------------------------------------------------------ | ---------------------------- | --------------------------- | | | | Oral Hygtene: | Good
fiF | | | • | | CPITIt | | 3 | | | | | 3 | zi | | | | Head & Neck /Soft Tissue: | 3 | 2-1
2 | | 4
5
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7
3
1 2
0
— 32
31 | 0 10 11 12 13 14 15 16
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30 20 20 27 28 25 24 23 22 21 20 10. 18
17 | | | | | CC | | | Classiticafion:
CLer | | | | | Nyt | Pain Sca:o: | | | | | F: PH | /10 | | | | | | | | | Dental Prostheses at intake: | | 0;p4c.=:
Comm b z
to | | - | | No
Yes
TWA:
Age: | | rt
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Ci10.54P-M4 | | Coml./ion:
Intro-oral Pholos Takert | | Radiographs Takert (Document findings on MO (Intimated | | | | Yes | | Yes 9 | | | | 0 | | | | | | Instructed how to obtain urgent and non-urgent dental care | | Yet I | No: | | | Treatment Priorities: | Nona: | Non-urgent
non-urgent | | Urgent Referred to Sick Cs& | | Ftadlographs authorized | | Prophylaxis authorized: | No
Yes I | | | PM:
BWt
Panorex | | (Approval valid 18 months from examination date) | | | | Prallent
Name:
4
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k | | | | | | l | | PDF | | Prosatbe0 by P6 00 | | Rep ces BP-A0818 01JUN 10 | # Bureau of Prisons Health Services | Clinical Encounter | | | | | | | | | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --------------------------------- | -------------- | --- | --- | --- | --- | --- | | EPSTEIN, JEFFREY EDWARD
Inmate Name:
Sex:
01/20/1953
Date of Birth:
Provider:
Encounter Date: 07/28/2019 20:25 | Reg #:
Facility: NYM
Unit: | 7631814
H01 | | | | | | | Nursing - Follow up encounter performed at Health Services.
SUBJECTIVE: | | | | | | | | | Provider:
COMPLAINT 1 | | | | | | | | | Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(les)
Inmate seen for F/U after returning from attorney conference offers no new complaints or
Subjective:
worsening S/S stets ° My R hand still has pins and needles sometimes" No change in
appearance from previous exam.
Pain:
No | | | | | | | | | OBJECTIVE: | | | | | | | | | Pulse: | | | | | | | | | Rate Per h1Intttn
),ovation
pate
Ilpt@
81
07/28/2019 20:28 | Provider
ftbytbra | | | | | | | | Respirations: | | | | | | | | | RlibLERLA1/1111.2 ProvidP
Time
Date
14
20:28 NYM
07/28/2019 | | | | | | | | | Blood Pressure: | | | | | | | | | b ocation
Value
Time
gust
157/91
07/28/2019 20:28 NYM | Provider
Cuff Size
Position | | | | | | | | SaO2: | | | | | | | | | ValuerM Ali
Time
Date
98
20:28 NYM
07/28/2019 | &nit | | | | | | | | Exam:
General
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 | Bureau of Prisons NYM | Page 1 or 2 | | | | | | | | | | | | | | | ![](_page_57_Figure_0.jpeg) | of
Prisons
Bureau
Services
Health
Cosign/Review | | | | | | | -------------------------------------------------------------- | ------------------------------------------------------------------------- | -------------------- | ----------------------- | ---------------------------- | ------------------------- | | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/28/2019 20:25 | Sex:
Prvider: | M | Reg #:
Race:
Facility: | 76318.054
WHITE
NYM | | Cosigned by | | on 07/2812019 20:50. | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Bureau of Prisons - NYM | | | | | Prisons
of
Bureau
Services
Health
Encounter
Clinical | | | -------------------------------------------------------------------------------------------------------------------------------------------- | ---------------------------------------------------------------------------------------------- | --------------------------------------------------- | | EPSTEIN, JEFFREY EDWARD
Inmate Name:
01/20/1953
Date of Birth:
Encounter Date: 07/28/2019 06:51 | Sex:
Provider: | 76318-q54
Reg #:
Facility: NYM
H01
Unit | | Nursing - Triage Note encounter performed at Health Services.
SUBJECTIVE: | | | | Provider
COMPLAINT 1
Chief Complaint: Neuropathy - Tingling/Numbness of Exlremity(les)
Subjective:
wanted to do'
Pain:
No | ' I woke up and I had no control over my Right arm for a few minutes it was just doing what it | | | OBJECTIVE:
Pulse:
Rate Per Minute
Itmg
Pate
82
07/28/2019 06:57 | Rhythm
"action. | Provider | | Respirations:
nine
Pate
06:57 NYM
07/28/2019 | Rate Per Minute Provider
14 | | | Blood Pressure:
Value
Location
Time
Pat
138/80
07/28/2019 08:57 NYM | Cuff Size
Position | provider | | Sa02:
Time
Value(%1 Alt
Rats
98
06:57 NYM
07/28/2019 | Provider | | | 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 | | | | Eyes
General
Yes: PERRLA, Extraocular Movements Intact | | | | Face
General
Yes: Symmetric
Generated 07/2812019 07:22 by | Bureau or Prisons - NYM | Pap 1 d 3 | | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/28/201906:51 | Sex:
Provider. | M | Race: WHITE | Reg #:
Facility: NYM
Unit: | 76318-054
Hal | | | ------------------------------ | ---------------------------------------------------------------------------------------------------------- | ----------------- | --- | ----------- | -------------------------------- | ---------------- | --- | | 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)
Contusion(s) R | | | | | | | | | | | | | | | | ROtcomments Received inmate AAOX3 In no acute distress, speaking In full sentenced ambulating independently C/C1 Right arm numbness after waking up from "sleeping on my tilde" that has since subsided. inmate interviewed in psyc obs through the slot V/S noted WNL, RR even and unlabored, no neurological deficits noted, no facial droop slurred speech or dysphagia, Inmate with Full ROM to all extremities with 4/4 strength bilaterally, slight swelling noted to right phalanges when compared to left, no edema, erythema or ecchymosis noted. Denies any pain numbness or tingli g at this time. Denies any Chest pain, Headache, Dizziness, SOB or Blurred vision. Eyes PERRLA. MD on Call notifl, Re-evaluate this evening or sooner if S/S persist #### ASSESSMENT: Alteration in comfort #### PLAN: #### Disposition: Follow-up et Sick Call as Needed Notify Medical Duty Officer #### Patient Education Topics: Hato Initiated Egnnat Bandoutfropic 07/28/2019 Counseling Plan of Care Ganuratod 07/28/2019 07.22 by Buroau of Prisons • NYM #### Outc me Verbalizes Understanding Page 2 of 3 | | | 76318-0
Reg #: | | | ----------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------- | ----------------------------- | ------- | | EPSTEIN, JEFFREY EDWARD
Inmate Name:
01/20/1953
Date of Birth:
Encounter Date: 07/28/2019 06:51 | Raco: WHITE
NI
Sex:
Provider: | Facility: NYM
H01
Unit: | | | Pate Initiated Format | Handout/Tonic | provider | Outcome | | Copay Required:No
No
TelephoneNerbal Order:
Completed by
Requested to be cosigned by
Cosign documentation will be displayed on the following page. | Cosign Required: Yes
on 07/28/2019 07:22 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | 76;18-054
Reg #:
EPSTEIN, JEFFREY EDWARD
Inmate Name:
WI- ITE
Race:
M
Sex:
01/20/1953
Date of Birth:
NYM
Facility:
Provider:
Encounter Date: 07/28/2019 06:51
on 07/28/2019 20:51.
Cosigned by | | of
Prisons
Bureau
Services
Health
Cosign/Review | | | | | | | | | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | -------------------------------------------------------------- | --- | --- | --- | --- | --- | --- | --- | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Bureau of Prisons - NYM | | | | | | | | | | | Inmate Name:
Date of Birth:
Note Date: | EPSTEIN, JEFFREY EDWARD
01/20/1953
07/26/2019 08:57 | Sex:
Provider. | Mli | Reg t/:
Facility:
Unit: | 76318-054
NYM
HO | | ---------------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------ | ------------------------------ | ----------------------------- | ----------------------------------------------------------------- | | Administrative Notes: | Cosign Note - Clinical Encounter Cosign encounter performed at Health Services.
ADMINISTRATIVE NOTE
1
THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM
2 NIGHTS AGO. | Provider: | | | | | Now Medication Orders:
Brit | Medicatim
Docusate Sodium Capsule | | Order Date
07/26/2019 08:57 | - Two Times | prescriber °mkt
TAKE ONE 104 MG CAP Orally
Day x 180 day(s) | | | Constipation, unspecified
Indication: | | | | | | Copay Required:No
TolephonoNerbal Order
Completed by | No | Cosign Required: No
on 07/26/2019 08:58 | | | | | | | | | | | Paso/d1 ## Bureau of Prisons Health Services Clinical Encounter - Administrative Note | Inmate Name:
Dale of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953 | Sex:
a | Reg #:
Facility:
Unit: | 76318.054
NYM
1101 | | -------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------ | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ---------------------------- | ------------------------ | | Note Date:
Administrative Notes:
Copay Required:No
TolophoneNerbal Order:
Completed by | 07/24/2019 16:10
ADMINISTRATIVE NOTE
1
2 NIGHTS AGO
No | Provider:
Cosign Note - Clinical Encounter Cosign encounter performed at Health Services.
Provider:
THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM
Cosign Required: No
2412019 16:12 | | | | Generated 07/24/2019 16:12 by | | Bureau of Prisons - NYNI | | Pogo 1 of I | ## Bureau of Prisons Health Services Clinical Encounter - Administrative Note | Inmate Namo:
Date of Birth:
Note Date: | EPSTEIN. JEFFREY EDWARD
01/20/1953
07/24/2019 16:10 | Sex:
Provider.
ide | Reg ft
Unit: | 16318-054
NYM
H01 | | ------------------------------------------------------------------------------------- | --------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --------------- | ----------------------- | | Administrative Notes:
Copay Required: No
TelephoneNerbal Order:
Completed by | ADMINISTRATIVE NOTE
1
2 NIGHTS AGO. | Cosign Note - Clinical Encounter Cosign encounter performed at Health Services.
Provider:
THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM
Cosign Required: No
24/2019 16:12 | | | | Generated 07/24/2019 16.12 by | | Bureau of Prisons - NYM | | Page 1 of 1 | | Bureau of
Prisons
Services
Health | | | | | | | | | | ------------------------------------------ | ------------------------------------------------------------------------- | ---- | ----------------------- | ---------------------------- | ------------------------- | --- | --- | --- | | Amendment
See | | | | | | | | | | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/26/2019 08:57 | Sex: | M | Reg #:
Race:
Facility: | 76318-054
WHITE
NYM | | | | | | Amendment made to this noto b | | on 07/2612019 08:58. | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Bureau al Prisons - NYM | | | | | | | | Clinical | Bureau
Health
Encounter | of | Prisons
Services
- Administrative | Note | | | | | -------------------------------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------ | --------- | --------------------------------------- | ---- | ---------------------------- | ------------------------- | ---------- | | Inmate Name:
Date of Birth:
Note Date: | EPSTEIN, JEFFREY EDWARD
01/20/1953
07/24/2019 15:10 | Sex: | Provider: | | | Reg #:
Facility:
Unit: | 763 rj 8-054
NY
H01 | | | Administrative Notes: | Admin Note - General Administrative Note encounter performed at Health Services.
ADMINISTRATIVE NOTE
1
PATIENT WAS OFFERED TO HAVE AN OPTOMETRIST EVALUATION. HE REFUSED. REFUSAL FORM
SIGNED. | Provider: | | | | | | | | Copay RequIred:No
TelophoneNerbal Order | No | Cosign Required: No
on 07/24/2019 15:17 | | | | | | | | Completed by | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Generated 07/24/2019 15:17 by | | | | Bureau of Prisons - NYM | | | | PEA 1 of 1 | | Bureau of Prisons
Health Services
Clinical Encounter | | | | | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ---------------------------- | --- | --- | | 7831
Reg St:
EPSTEIN, JEFFREY EDWARD
Inmate Name:
Facility: NYM
SitigiTE
Sex:
01/20/1953
Date of Birth:
1101
Unit:
Encounter Date: 07/24/2019 13:08
Provider. | | | | | Mid Level Provider - Follow up Visit encounter performed at Receiving & Discharge.
SUBJECTIVE: | | | | | Provider:
COMPLAINT 1
Chief Complaint: Other Problem
I still do not want to talk about. But, between you and me. I think my room mate had to do with
Subjective:
what happened to me. Do not ask me. I am not going to say anything.
Pain:
No | | | | | OBJECTIVE:
Temperature:
Provider
bocatIon
Fahrenheit
Celsius
Time
Dam
36.6 Oral
97.8
13:12 NYM
07/24/2019 | | | | | Pulse:
awl=
provider
Location
Rate Per Minute
Time
Data
Regular
Via Machine
83
07/24/2019 13:12 | | | | | Blood Pressure:
Position
Cadillac
ai
m
Value
bocation.
Time
Pita
Adult-regular
Sitting
Right Arm
132/89
07/24/2019 13:12 NYM | | | | | SaO2:
Provider
Value(%J Alr
Time
Age
96 Room Air
13:12 NYM
07/24/2019 | | | | | Exam:
General
Affect | | | | | Yes: Cooperative
Appearance
Yes: Appears Well, Alert and Oriented x 3
No: Appears Distressed, Appears in Pain | | | | | Exam Comments
Follow up evaluation done for inmate Epstein.
He does not look in any pain or distress.
He still has the erythema around his neck. Central part of this erythema has some abrasion. Patient do
of any respiratory problem or distress. He still does not want to explain how the skin Injury on his neck | s not complaint
apped. he | | | | Insinuates that injuries on his neck have to do with his room mate. But does not want to talk about it.
ASSESSMENT: | | | | | Injury, unspecified, T1490 - Current | | | | | PLAN: | | | | | Disposition:
Bureau of Prisons - NYM
Generated 07/241201913:24 by | Pastier 2 | | | | Inmate Name:
Date of Birth:
Encounter Date: 07/24/201913:08 | EPSTEIN, JEFFREY EDWARD
01/20/1953 | WHITE
Sex:
Provider: | 76318-054
Reg #:
Facility: NYM
H01
Unit: | | | ------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------ | ------------------------------------------------------- | ---------------------------------------------------- | --------------------------------------------------------------------- | | | Follow-up at Sick Call as Needed | | | | | Patient Education Topics:
Date Initiated Format
07/24/2019
07/24/2019 | Counseling
Counseling | liartdcatt,Marda
Access to Care
Preventive Health | | Outcome
Verbalizes
Understanding
Verbalizes
Understanding | | Copay Required: No
TelephoneNerbal Order:
Completed by
Requested to be cosigned by | No
on 07/24/2019 13:24
Cosign documentation will be displayed on the following page. | Cosign Required: Yes | | | | Prisons
of
Bureau
Services
Health
Cosign/Review | | | | | | | -------------------------------------------------------------- | ------------------------------------------------------------------------- | ----------------- | ----------------------- | ---------------------------- | ------------------------- | | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/24/2019 13:08 | Sex:
Provider: | lam | Reg #:
Race:
Facility: | 76318-O54
WHITE
NYM | | | Cosigned with New Encounter Note by Millain | | 07/24/2019 16:10. | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Bureau of Prisons - NYM | | | # Bureau of Prisons Health Services | Encounter
Clinical | | | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ----------- | | 76318-0
Reg #:
EPSTEIN, JEFFREY EDWARD
Inmate Name:
Facility: NYM
ITE
Sex:
01/20/1953
Date of Birth:
H01
Unit:
Provider.
Encounter Date: 07123/2019 06:20 | | | Injury Assessment - Non-work related encounter performed at Health Services. | | | SUBJECTIVE:
Provider: | | | INJURY
1
07/23/2019 08:25
Date Reported for Treatment:
07/23/2019 01:27 | | | Date of injury:
UNASSG
Work Assignment:
Work Related:
No | | | | | | Pain Location:
0 | | | Pain Scale:
Pain Qualities: | | | Where Did Injury Happen (Be specific as to location): | | | Special Housing Unit ZO5-Cell 124 L | | | Cause of Injury (Inmate's Statement of how injury occurred): | | | 'I do not know. Just went to drink a little water and wake up snorting'. | | | Symptoms (as reported by inmate): | | | None | | | | | | OBJECTIVE:
Temperature: | | | provider
Location
etslt
Fahrenheit
Dant
rime.
36.4 Oral
06:30 NYM
97.5
07/23/2019 | | | Pulse: | | | Provider
Matra
Rate Par MInutg
Location
hint.
nag | | | Regular
Via Machine
92
07/23/2019 06:30 | | | Respirations: | | | Rate Per Minute Provider
DAM
flint | | | 16
06:30 NYM
07/23/2019 | | | Blood Pressure: | | | Provider
Cuff Sixk
Time
Position
Data
Valise
Location
Adult-regular
Right Arm
Sitting
140/85
07/23/2019 06:30 NYM | | | SaO2: | | | Valuel%I
Time
Air
Provider
PAM | | | 96 Room Air
06:30 NYM
07/23/2019 | | | Exam: | | | General | | | Affect | | | Yes: Cooperative | | | Appearance | | | Yes: Appears Well, Alert and Oriented x 3 | | | No: Appears Distressed, Lethargic, Dyspneic. Appears in Pain, Pallor. Cyanotic. Diaphoretic, Disheveled, | | | Bureau of Prisons • NNW
Gonerztod 01123/2019 09:05 by | Page 1 of 2 | | EPSTEIN, JEFFREY EDWARD
Inmate Name:
01/20/1953
Date of Birth:
Encounter Date: 07/23/2019 06:20 | ITE
Sex:
Provider: | 76318-064
Reg ff:
Facility-. NYM
1101
Unit: | | | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------ | ------------------------------------------------------- | ------------------------------------------------ | | Exam: | | | | | Acutely III | | | | | Pulmonary | | | | | Auscultation
Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally | | | | | No: Crackles, Rhonchi, Wheezing | | | | | | | | | | Fxam Comments
Inmate for injury report as requested by Operational Lt.
He is ambulatory, oriented x 3. In not apparent distress, smiling during this
know what happened. Can not explain the marks on his neck Responded: "I don't know".
He does not want to talk of the events leading to the marks on his neck.
He does not look in any distress or pain.
Has an circular line of erythema at the base of the neck. Reaching 2/3 of the neck circumference, 2 inch
the back of the neck. Has one section of this erythema In the front with marks of friction.
No Inflammation, no deformities, no hematomas, no lacerations, no tenderness. Patient moving his neck
restriction. Denies having any pain or discomfort Denies any respiratory problem.
Has another small erythema on left knee about 2cm In diameter(mild).
As per Information from custody staff Inmate Epstein was found in his cell with a rope around his neck a
floor.
Inmate is currently placed on suicide watch.
ASSESSMENT: | | clinical encounter. Alleges, that he does not | wide, sparing
without any
d sitting on the | | Injury, unspecified, T1490 - Current - R/O self inflicted infuties. | | | | | PLAN: | | | | | Disposition: | | | | | Follow-up at Sick Call as Needed
Placed on Suicide Watch
Follow-up In 2-4 Hours | | | | | Other. | | | | | For follow up with psychology service. | | | | | Patient Education Topics: | | | | | Bate InitiateeFormat | Handout/Topic | | Outcome | | Counseling
07/23/2019 | Access to Care | Sin | Verbalizes
Understanding | | Counseling
07/23/2019 | Plan of Care | | Verbalizes
Understanding | | Copay Required: No
No
TelephoneNerbal Order | Cosign Required: Yes | | | | on 07/23/2019 09:05
Completed by | | | | | Requested to be cosigned by | | | | | Cosign documentation will be displayed on the following page. | | | | | | | | | | Genuratod 07232019 09:05 by | Bureau of Prisons - NYM | | Page 2 of 2 | | | Prisons
of
Bureau
Services
Health
Cosign/Review | | | | | | ------------------------------ | ------------------------------------------------------------------------- | ------------------- | ----------------------- | ---------------------------- | ------------------------- | | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/23/2019 06:20 | Sex:
Provider. | | Reg #:
Race:
Facility: | 76318-054
WHITE
NYM | | Cosigned by | | n 07/2312019 15:44. | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Bureau of Prisons - NYM | | | | | Prisons
of
Bureau
Services
Health
Encounter
Clinical | | | | ----------------------------------------------------------------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ---------------------------------------------------- | --- | | EPSTEIN, JEFFREY EDWARD
Inmate Name:
01/20/1953
Date of Birth:
Encounter Date: 07/14/2019 17:36 | Race: WHITE
NI
Sex:
Provider: | 76318-654
Reg If:
Fadlity: NYM
Z05
Unit: | | | | Chronic Care - 14 Day Physician Eval encounter performed at Health Services. | | | | SUBJECTIVE: | | | | | COMPLAINT 1 | Provider: | | | | Chief Complaint: ENDO/LIPID
Subjective: | 66 YR OLD WHITE MALE WITH HX OF
HYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRILL WAS
800 , NOW 431. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE
MEDS DUE TO THEIR GI SIDE EFFECTS.
I-IX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CP
MACHINE. STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTE
STATES THE FBI LOKELY HAS
L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE
LOWER EXTREMITIES.
SURGICAL HX: NONE | | | | Pain:
Yes | MENTAL HEALTH HX: NONE | | | | 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): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid | | | | | Added to clinic(s): Orthopedlc/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid | | | | OBJECTIVE: | | | | | Exam: | | | | | General | | | | | Appearance | | | | | | Yes: Appears Well, Alert and Oriented x 3 | | | | Disheveled, Unkempt, Acutely III | No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain. Pale, Pallor, Cyanotic. Diaphoretic, | | | | Nutrition | | | | Gonera:ad 07114/2019 18:11 by Bureau of Prisons. NYM Page 1 of 3 No: Appears Obese Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM | | Encounter Date: 07/14/2019 17:36 | Provider: | | Unit: | Z05 | | -------------------------- | ---------------------------------------------------- | ------------------------ | ---------------- | ---------------- | ------------------------------------------------------------------------- | | Exam: | | | | | | | Eyes | | | | | | | General | | | | | | | | Yes: PERRLA, Extraccular Movements Intact | | | | | | Pulmonary | | | | | | | Auscultation | | | | | | | | Yes: Clear to Auscultation | | | | | | Cardiovascular | | | | | | | | Auscultation | | | | | | | Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2 | | | | | | Abdomen | No: M/R/G | | | | | | | 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: | | | | | | | E.Idt | Medication | | \_Pat
larder | | Prescriber Order | | | Omega 3 ( Vascepa) 1 GM Capsule | | 07/14/2019 17:36 | | TAKE 2 CAPS Orally - Two
Times a Day x 180 day(s) —
TAKE WITH FOOD. | | | Indication: Hyperlipidemia, unspecified | | | | | | New Laboratory Requests: | | | | | | | Details | | Frequency | Pue Date | | | | | Lab Tests-hi-Hemoglobin A1C | Ono Timo | | 10/10/2019 00:00 | Routine | | | Lab Tests-L-Lipid Profile | | | | | | Genera:4d 07/14201918:11 b | Additional Information: | Bureau of Prilocns - NYM | | | Page 2 of 3 | | | | | | | | | EPSTEIN, JEFFREY EDWARD
Inmate Name:
01/20/1953
Date of Birth:
Encounter Date: 07/14/2019 17:36 | WM&
Sex:
Provider: | Reg #:
Fed\*: NYM
Un | 76318-0
205 | | | ------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------ | ----------------------------------- | -------------- | --------------------------- | | FASTING.
Lab Tests-H-Hep B surface Ab
Lab Tests-H•Hep B surface Ag
Lab Tests-H-Hep C Ab
Lab Tests-H-Hepatic Profile | One Time | 08/08/2019 00:00 | Rou | | | Schedule: | | | | | | Activity | Date Scheduled | Scheduled Provider | | | | Clinical Encounter | 07/24/2019 00:00 Optometrist | | | | | 66 YR OLD MALE FOR ROUTINE SCREENING. | | 01/07/2020 00:00 Mid-Level Provider | | | | Chronic Care Visit | | | | | | 6 MONTH F/U. | 07/01/2020 00:00 Physician 01 | | | | | Chronic Care Visit | | | | | | Other:
PENDING EKG AND FOBT. CXR WAS REFUSED. | | | | | | Patient Education Topics: | | | | | | Pate initiated format
Counseling
07/14/2019 | Handout/Topic
Diagnosis | | | Verbalizes
Understanding | | Copay Required: No
No
TelophoneNerbal Order:
Completed by | Cosign Required: No
on 07/14/2019 18:11 | | | | | Generated 07/14/2019 18:11 by | &ruau of Prisons - NYM | | | Page3c4 3 | BP-S358.060 SEP 05 # MEDICAL TREATMENT REFUSAL CDERM ### U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the F nit Bureau of Prisons Medical staff for the following condition(s): #### DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: #### EYE DOCTOR EVALUATION. #### The following treatments) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment l hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expresses •"rections. | 7-24-2019
Counseled by | Date | | | ------------------------- | ---- | --- | | Simalure of Witne s | Date | | | | | | # MEDICAL TREATMENT REFUSAL CDFRM | | OF
PRISONS
BUREAU
FEDERAL | | ----------------------------------- | ---------------------------------- | | JUSTICE
OF
DEPARTMENT
U.S. | | BP-5358.C50 SEP 05 #### 7-10-2019 Date | EPSTEIN
JEFFREY
I,
Prisons Medical
Bureau of | 76318-054
following condition(s):
staff
for
the | treatment recommended
by
, refuse | e Federal | | | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | -------------------------------------------------------------------- | ----------------------------------------------------------------- | --------------------------------- | --- | | IN
CONDITION
DESCRIBE | TERMINOLOGY:
LAYMAN'S | | | | | NO
WITH
MALE
OLD
66 YR | FOR
, REFERRED
PMHX | CXR.
ROUITNE | | | | | | | | | | | | | | | | | | | | | | The | following treatment(s)wasfwere recommended: | | | | | CHEST
X-RAY | | | | | | | | | | | | | | | | | | Bureau of
Federal
consequences and/or
possible | members have
staff
Prisons Medical
complications may result | explained,to me that the
carefully
my refusal
because of | following
to accept treatment: | | | WORSENING THE CONDITION | FINDINGS
IS
ANY
IF
THERE | | | | | | | | | | | | | | | | | | | | | | | still
refuse
above, and
complications, listed
consequences and/or
possible
understand
the
I
condition, and
and/or
mental
my physical
responsibility for
assume all
hereby
recommended
treatment. I
following my
respecting and
liability for
and
all
its employees from any
Prisons and
Bureau of
release the | | | | | | wishes and
expressed | directions. | | | | | | | | | | | Counseled
by | 7-10-2019
Date | ianature
Patien | Date | | | | | | | | | Signature of
Witness | | | | | | | | | | | | | | | | | SEP 05 ## U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7.24-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the folloWing possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse II recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and°flowing my expressed wishes and directions. | Counseled by | 7-24-2019
Date | Pa | | ----------------------------- | ----------------- | ---------------- | | INERSC
Signature of Wtne s | Date Si. | NYM-NEW YORK MCC | Date # 8P-A0618 A&O DENTAL EXAMINATION JUN 18 (Initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS | | Occlusion: | | | ------------------------------------------------------------------------- | --------------------------------------------------------------- | ---------------------------- | | | Fart
Good
Oral Hygiene: | loot
T | | | | | | | | 3
2f | | •
• | CPITN: | | | | 3 | | | | 3 | 2
3
- | | | Head & Nedt / Soft Tissue: | | | 9 10 11 1213 14. 15
11
7
El
5 6
3
4
2
1 | | | | 28 25 2423 22 21 20 19 • 18
17 21
30 29 29 27
L-9 32
31
cc | Classcalien: | | | | 10
U | | | | | | | | Pain Scale:
F: i
l l | | | | | /10 | | Nq01iii1 | | | | /! | | | | | rwC
iv
•
azr | | | Dental Prostheses at Intake: | • | 125A
ta
, | | No
Yes | cc02
secu42
SS
on Olo | | | Typo: As
: | 'ei
4
,
or
za
- c
cd-o-tgiAc
| 0.10.9—A/64 | | Condit:on: | ,,,
Radiographs Talton: (Document findings on A8O encounter) | | | Intra-cral Photos Taken: | | | | Yes | Yes 9
• | | | | | | | tnstruded how to obtain urgent and non-urgant dental care: | No:
Yes: I | | | None:
Treatment Prianles: | Nan-urgett | Urgent Reterrgd to Sick Cal: | | | non-urgent | | | Radiographs authorized: | Yes i
Prophylaxis audionzeet | No | | PM: | (Approval valid 18 months from examination date) | | | BWs | | | | Panorec | | | | Name:
la;51ent | | | | -cc-Pity
-3
)
i
r
st?
\_ .— | | SI. nature Bin k/Stamp: | | Institution: /
W441
tanner: | Date: | | | 76
OS1
Se-
I
MCC NEW YORK
3 | 7-26-19 | cer | | | Uhtet Uent
MCC New York | | | | | | | PDF | Prescribed by P6400 | Replaces SP-A0018 o1 JUN 10 | | | | | #### A&O DENTAL EXAMINATION (Initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS JUN 18 U.S. DEPARTMENT OF JUSTICE BP-A0818 | | | —Occlusion: | | | | | ---------------------------------------------------------- | ---------------------------------------------------- | ------------------------------------------------ | --------------- | ----------------------------- | ----------- | | | | Oral Hygiene: | Good | Fatt | | | | | | | | | | | | | | | | | | | CPITN: | 3 | | 3 | | | | | | 2 | | | | | | 3 | - | | | 1
5 0 7
3 | 6
0 1011 1213 14 15
0 | Head & Neck I Soft Yrsus | | | | | g
2
31
— 32 | 5
313 29 28 27 28 25 2125 22 21 20 19 • 18
117 | | | | | | % | \\ | | Classification: | | | | | | | | | | | | | I LI
F: | Pain Scaio: | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Dental Prosth~s at Intake: | | of
CommAll
—0 | | k25 ikkj | | | Yes
Typo: | | ri 4-4/
P
ab
CC-O255/Oin | Suue- | F | | | Age: | | Za-le-c
t--N—V-1 | or | Cass0-7/1' 0 29-Sefik4 | | | Condltkin:
Intro-oral Photos Taken: | | Radiographs Taken: (Document findings on MO | | | encounter) | | Yes | | Yes | | | | | 0 | | Do | | | | | | | Yes: i | No: | | | | InstruMad how to obtain urgent and non-urgent denial care: | | | | | | | Treatment Priorites: | None: | Non-urgent
non-urgent | | Urgent Reforrld to Sick Call: | | | Radiographs outorizedi | ' | Prophylaxis authorized: | Yes' I | No | | | | | (Approval valid 18 months from examination dato) | | | | | PAs:
BWm | | | | | | | PanOreiC | | | | | | | Pieta Name: | E | Dentist
nature: | | | | | i
--tin
s
4 | —a --esip
z.v | | | | ock/Stamp: | | FarsteNrsalsa:
os-ki
3
IQ=
76 | Institution: /
MCC NEW YORK | Date:
26
1
9
7 | Signature | | | | | | -
- | •
et | en aOfficer | | | | | | MCC | York
New | | | | | | | | | | PCF | | Presaibecl by P6900 | | ' ~son | 18 OfJUN 10 | | | | | | | | | | | | | | | SEP 05 # U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-20q9 Date | 76318-054
I, JEFFREY EPSTEIN
Bureau of Prisons Medical staff for the following condition(s): | refuse treatment recommended by the Federal | | | | | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------- | ---------- | --- | --- | | DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: | | | | | | EYE DOCTOR EVALUATION. | | | | | | | | | | | | | | | | | | | | | | | | The following treatment(s) was/were recommended: | | | | | | EYE DOCTOR EVALUATION. | | | | | | | | | | | | | | | | | | | | | | | | Federal Bureau of Prisons Medical staff members have carefully explained to me that the following
possible consequences and/or complications may result because of my refusal to accept treatment: | | | | | | INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. | | | | | | | | | | | | | | | | | | | | | | | | I understand the possible consequences and/or complications, listed above, and still refuse
ditlon, and
recommended treatment I hereby assume all responsibility for my physical andlor mental co | | | | | | release the Bureau of Prisons and its employees from any and all liability for respecting and f
irectlons.
expressed | | 'lowing my | | | | | | | | | | 7-24-2019 | | | | | | Date
Counseled by | nt's Sign
Pa | Date | | | | | | | | | | | | | | | | Date
Signature of VVitne s | NYM-NEW YORK MCC | | | | | | | | | | | | | | | | | | | | | | | Federal
Bureau of | Medical
U
S | Federal
Center
for | Prisons | | | -------------------------------------------------------------- | --------------------- | ------------------------ | -------- | ---------------------------------- | | O
Prisons | | | | | | | | | | ••• Sensitive But Unclassified ••• | | Name EPSTEIN, JEFFREY | Facility | MCC New York | | Collected 07/09/2019 13:34 | | | Order Unit E06-547U | | | Received 07/10/201 10:44 | | Reg tt 76318-054
DOB
01/20/1953 | Provider | | | Reported 07/10/10 914:48 | | M
Sox | | | LIS ID | 188191004 | | | | | | | | | | HIV | | | | | | | Negative | | | HIV 1/2 | Negative | | | | | Screening test - See confirmatory testing for Reactive results | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | FLAG LEGEND | L=Low LI=Low Critical | H=High HI=High Critical | | A=Abnormal Al =Abnomlal Critical | | | | | | Page 3 of 3 | | | | | | | | | | | | | | | | | | | # Bureau of Prisons Health Services Cosign/Review | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/10/2019 16:58 | Sex:
Provider: | M
Lab Result Receive | Reg t\$:
Race:
Facility: | 76318-054
WHITE
NYM | | ------------------------------ | ------------------------------------------------------------------------- | ------------------- | ----------------------- | ----------------------------- | ------------------------- | | Cosigned by | | on 07114/201918:12. | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Bureau of Prisons NYM | | | | | | | | | | | BP-S358.C60
SEP 05 | MEDICAL TREATMENT REFUSAL | CDFRM | | ------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ----- | | U.S. DEPARTMENT OF JUSTICE | FEDERAL BUREAU OF PRISONS | | | | 7-24-20i9
Date | | | I, JEFFREY EPSTEIN
Bureau of Prisons Medical staff for the following condition(s): | refuse treatment recommended by the Federal
76318-054 | | | DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: | | | | EYE DOCTOR EVALUATION. | | | | | | | | The following treatment(s) was/were recommended: | | | | EYE DOCTOR EVALUATION. | | | | | | | | | Federal Bureau of Prisons Medical staff members have carefully explained to me that the following
possible consequences and/or complications may result because of my refusal to accept treatment: | | | INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. | | | | | | | | expressed wishes and directions. | I understand the possible consequences and/or complications, listed above, and still refuse
recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and
release the Bureau of Prisons and Its employees from any and all liability for respecting and following my | | | | | | | Counseled by | 7-24-2019
Date | | | M | | | | illterigr
S !nature of Wino | NYM-NEW YORK MCC
Date | | #### BP-A0818 A&O DENTAL EXAMINATION JUN 18 (Initial Clinical Dental Findings) ### U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OR PRISONS ![](_page_86_Figure_4.jpeg) - Replaces BP-A0618 of JUN 10 | MEDICAL TREATMENT REFUSAL
SP-S358.060
sEF os | | coFF.M | | ------------------------------------------------------------------------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------ | | U.S. DEPARTMENT OF JUSTICE | FEDERAL BUREAU OF PRISONS | | | | 7-24-2019
Date | | | | | | | I, JEFFREY EPSTEIN
Bureau of Prisons Medical staff for the following condition(s): | , refuse treatment recommended by the Federal
76318-054 | | | DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: | | | | EYE DOCTOR EVALUATION. | | | | | | | | | | | | | | | | The following treatments) was/were recommended: | | | | EYE DOCTOR EVALUATION. | | | | | | | | | | | | | | | | | Federal Bureau of Prisons Medical staff members have carefully explained to me that the following
possible consequences and/or complications may result because of my refusal to accept treatment | | | INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. | | | | | | | | | | | | | | | | | I understand the possible consequences and/or complications, listed above, and still refuse
recommended treatment I hereby assume all responsibility for my physical and/or mental condition, and | | | | release the Bureau of Prisons and Its employees from any and all liability for respecting and following my | | | expressed wishes and directions. | | | | | | | | | 7-24-2019
I's Sign
Date
a | Dale | | Counseled by | | | | | | | | | NYM-NEW YORK MCC | | | Signature of VVitn | Date | | | | | | • | BP-S358.C50 | MEDICAL TREATMENT REFUSAL | CDERM | | ----------- | ------------------------- | ----- | | | | | | SEP 05 | | | ------ | --- | # U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS # 7-10-2019 Date JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: 66 YR OLD MALE WITH NO PMHX REFERRED FOR ROUITNE CXR. The following treatment(s) waslwere recommended: CHEST X-RAY Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: WORSENING THE CONDITION IF THERE IS ANY FINDINGS I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. | Counseled by | 7-10-2019
Date | Signature
Patien | Date | | ---------------- | ----------------- | ------------------- | ---- | | gnature o
ess | Date | NYM—NEW YORK MCC | | #### A&O DENTAL EXAMINATION (Initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS JUN 18 U.S. DEPARTMENT OF JUSTICE BP-A0818 | | 0ccluslon: | | | | ---------------------------------------------------------------- | ------------------------------------------------ | ---------------------------- | --------------------------- | | | | | | | | | | | | | | | | | | | | | | | | | | | | Head & Neck / Soft Tissue: | | | | 5
8 1011 1213 14 15 185
5 0 7
8
3
4
1 2 | | | | | 30 20 28 27 28252423 22 21 20 10 • 18
17
31
32 | | Classification: | | | | | | | | | 1 | CL
| | | | | Pain Scale: | | | 9)1711'1)111i14?
El | | | | | 1
1»
iffig | | | | | | | | | | Dental Pros-Tones at Intake: | .6,
C
a
ramr
om | an | | | No
Yes | Pi
g
on DIDSero-e
rk.02 SS J | • | | | Type:
Agt: | Ad
4,—Ler C—N. | Co14.in 5
or | SCJAled | | Concliticn:
Infra-oral Photos Taken: | Radiographs Taken: (Document findings on A&O | | | | Yes | | | | | | Yes 9 | | | | 0
Instructed how to cbtain urgent and non-urgent dental care: | Yes: / | I
No: | | | i None:
Treatment Pdarlitis: | Non-urgent | Urgent Referred to S?ck Galt | | | | non-urgent | | | | Radiographs authodzed: | Prophyiaes authorized: | No
Yes i | | | PAT | (Approval valid 18 months from examinafion date) | | | | BA
Pence« | | | | | Pen Naaw i | Don' | | | | slcin
1
Jed-
-Pe-y
s | | | | | stf
hlurnben
f
Institution: / | Date: | SI nature lock/Stamp: | | | os-Ai
3
i
Sit
-76
YORK
MCC
NEW
, | 2
6
1
7
9
-
--
- | | | | | | et
MCC
New | en a (Juicer
York | | | | | | | PDF | Presatbee by P6400 | | Replaces BP-A0518 or JUN 10 | | | | | | ## Bureau of Prisons Health Services Clinical Encounter | Inmate Name:
Date of Birth:
Encounter Date: 08/10/2019 07:25 | EPSTEIN, JEFFREY EDWARD
01/20/1953 | Sex:
Provider: 'MIME | M | | Race: WHITE | Reg #:
Facility: NYM
Unit | 76318-034
Z04 | | | ------------------------------------------------------------------ | ---------------------------------------------------------------------------------------- | ----------------------- | --- | ---------------- | ----------- | ------------------------------- | ---------------- | --- | | | | | | | | | | | | | Emergency Code - Resuscitation Event encounter performed at Special Housing Unit. | | | | | | | | | SUBJECTIVE: | | | | | | | | | | Emergency Note | Provider. | | | | | | | | | Team Members: | | | | | | | | | | Provider | | | | | | | | | | | | | | Team/Code Leader | | | | | | Code Events: | | | | | | | | | | Ufa | Value | | | | | Data | | | | CPR | Compressions | | | | | 08/10/2019 06:35 | | | | EKG/Monitor | Lifepak | | | | | 08/10/2019 06:39 | | | | No shock advised | | | | | | | | | | CPR | Compressions | | | | | 08/10/2019 06:40 | | | | Oxygen | 15 L | | | | | 08/10/2019 06:47 | | | | IV Access | Peripheral IV | | | | | 08/10/2019 | 06:48 | | | 18 g Left AC | | | | | | | | | | Airway | Endotracheal Tube | | | | | 08/10/2019 07:08 | | | | | ET Tube 7.5 24CM to L Up line Placed by Paramedics | | | | | 08/10/2019 07:10 | | | | Medications | Epinephrine 1mg IV | | | | | | | | | CPR | Epinephrine 3 doses and Sodium bicarb 2 doses administered by paramedics
Compressions | | | | | 08/10/2019 07:11 | | | | Medications | Sodium Bicarbonate 1 mEa/kg N | | | | | 08/10/2019 07:11 | | | | IV Fluids | Normal Saline 0.9% 1000 ml | | | | | 08/10/2019 07:12 | | | | | Epinephrine 1mg IV | | | | | 08/10/2019 07:13 | | | | Medications | | | | | | 08/10/2019 07:14 | | | | CPR | Compressions
Sodium Bicarbonate 1 mEa/kg IV | | | | | 08/10/2019 07:14 | | | | Medications | | | | | | 08/10/2019 07:16 | | | | Medications | Epinephrine 1mg IV | | | | | 08/10/2019 07:17 | | | | CPR | Compressions | | | | | | | | #### Comments: Responded to a body alarm at 0635 for medical emergency on 9S, Upon arrival Inmate was received on the floor of his cell unresponsive with CPR In progress by correctional officers, Inmate was Cold, with circumferential Bruising around the neck and posterior mottling, Pupils Fixed and dilated, No Palpable pulses, Cali place for EMS, CPR Continued. AED Placed No shock advised, CPR Continued, inmate transported to HSU treatment room with CPR in progress, 18g hep lock to L AC, 02 15 Lt VIA BVM, Pulse Check NO SHOCK advised. EMS and Paramedics arrived 0656, PlaCed on cardiac monitor asystole Resumed CPR, Inmate was intubated by Medics, 3 Rounds of Epinephrine administered. Pulse Check asystole, Inmate was transported to Local ER with CPR in progress. #### OBJECTIVE: Exam: General Appearance Yes: Unconscious Generated 08/10/2019 08:10 by Buroau of Prisons - NYM Pogo 1 of 2 | EPSTEIN, JEFFREY EDWARD
Inmate Name:
01/20/1953
Date of Birth:
Encounter Date: 08/10/2019 07:25 | | Sex:
SSW.
Provider: | | Reg #:
Facility: NYM
Unit: | 76318-054
Z04 | | | ------------------------------------------------------------------------------------------------------------------------------------------------------------------ | ------------------------------------------- | ------------------------------------------- | -------- | -------------------------------- | ---------------- | ----------- | | Exam:
ASSESSMENT:
Cardiac Arrest | | | | | | | | PLAN: | | | | | | | | New Consultation Requests:
Consultation/Procedure
Emergency Room
Subtype:
AMBULANCE
Reason for Request:
Cardiac arrest with CPR in progress | Target Date
08/10/2019 | Scheduled Targeingta Priority
08/10/2019 | Emergent | | Translate!
No | Language | | Copay Required:No
TelophoneNerbal Order:
No
Completed by\_
Requested to be cosigned by
Cosign documentation will be displayed on the following page. | Cosign Required: Yes
on 08/10/2019 08:10 | | | | | | | | | | | | | | | | | | | | | | | Generated 08/10/2019 08:10 by | | Bureau of Prisom - NYM | | | | Page 2 of 2 | | | | | | | | | | | of
Prisons
Bureau
Services
Health | | | ----------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --------------------------------------------- | | | Encounter
Clinical | | | EPSTEIN, JEFFREY EDWARD
Inmate Name:
01/20/1953
Dale of Birth:
Encounter Date: 07/30/2019 15:58 | Provider.
Provider. | 76318-054
Reg #:
Facilit
Unit
Z01 | | Chronic Care - Chronic Care Clinic encounter performed at Health Services. | | | | SUBJECTIVE: | | | | Provider:
COMPLAINT 1 | | | | Chief Complaint: Other Problem | | | | Subjective:
SPEAKING OR SWALLOWING.
TOPROL.
HIM TONIGHT
HE REPORT OTHER NON-MEDICAL ISSUES. | 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
HE REPORTS NOCTURIA OF ABOUT 5 TIMES,. HE DENIES DYSURIA.
HE REPORTS H OF KIDNEY STONES, HX OF HTN FOR WHICH HE WAS TAKING
HE ANS A HX OF SLEEP APNEA AND STATED HE HAS NOT SLEPT FOR 3 WEE S
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 GIVE TO | | | STATES HE FEELS OTHERWISE FINE.
Pain: | | | | Not Applicable | | | | Seen for clInic(s): Pulmonary/Respiratory, Orthopedic/Rheumatology, Endocrtne/Lipid | | | | OBJECTIVE: | | | | Exam: | | | | General | | | | Affect | | | | Yes: Cooperative | | | | Appearance | | | | Yes: Appears Well, Alert and Oriented x 3 | | | | Disheveled, Unkempt, Acutely III | No: Appears Distressed, Dyspneic, Appears in Pain, Writhing In Pain, Pale, Pallor, Cyanotic, | | | Nutrition | | | | No: Appears Obese | | | | Pulmonary | | | | Auscultation | | | | Yes: Clear to Auscultation | | | | Cardiovascular
Auscultation | | | | Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2 | | | | No: MIRJG | | | | Musculoskeletal | | | | Tibia / Fibula | | | | No: Edema | | | | Neurologic | | | | Generated 07/3012019 16:12 | Bureau or Prlacnu - NYM | Pi. 1 of 2 | | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07130/2019 15:58 | Sex:
Provider. | | 76318-064
Reg #:
Facility NYM
Z01
Unit | | | ----------------------------------------------------------- | ------------------------------------------------------------------------- | ----------------------- | ---------------- | ---------------------------------------------------------------- | ---------------------------------- | | Exam: | | | | | | | | Cranial Nerves (CN) | | | | | | | Yes: Within Normal Limits | | | | | | | Motor System-General | | | | | | | Yes: Normal Exam | | | | | | | Motor System-Strength
Yes: Normal Muscular Strength | | | | | | ASSESSMENT: | | | | | | | | | | | | | | | Body mass Index (BMI) 27.0-27.9, adult, Z6827 - Current | | | | | | | Constipation, unspecified, K5900 - Current | | | | | | | Essential (primary) hypertension, 110 - Current - BY HX. | | | | | | | Hyperlipldemla, 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: | | | Order Data | Prescriber Order | | | 132:tt | Medication(
INsulin REG - Human | | 07/30/2019 15:58 | SLIDING SCALE
7 day(s) Pill Line Only | Subcutaneously each morning x | | | Indication: Prediabetes | | | | | | | Discontinued Medication Orders: | | | | | | Rx# | Medication | | Order Date | prescriber Order | | | 122148-NYM | Insulin Reg (10 ML) 100 UNITS/ML Inj | | 07/30/2019 15:58 | Inject regular insulin
twice daily "'pit line"' for 7
days | subcutaneously) per sliding scale: | | | Discontinue Type: | When Pharmacy Processes | | | | | | Discontinue Reason:now order written
Indication: | | | | | | Copay Required: No
TelophonoNerbal Order
Completed by | No
on 07/30/2019 16:12 | Cosign Required: No | | | | | Gorteralud 07/30/2019 16:12 by | | | Banal of Non NYM | | Papas( 2 | #### Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/30/2019 11:12 Sex: Provider: Reg It: 76318.054 Facility: NYM Unit: 201 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT PATIEN ALSO STAT HE DENIES SPEAKING ca. HE REPORT HE REPORTS H TOPROL. HE AHS A HX OF SLEEP ISNCE HE HASS EEN INFORME DHIM THAT WE R HIM TONIGHT.. HE REPORT OTHER NON-ME STATES HE FEELS OTHERWISE Pain: Not Applicable S REFERRED BY THE WARDEN FOR EVALUATION. RTS HE HAS BEEN WITHOUT HIS MEOS FOR ABOUT 1 WEEK. HE S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY OWING. IA OF ABOUT 5 TIMES.. HE DENIES DYSURIA. ONEY STONES. HX OF HTN FOR WHICH HE WAS TAKING AND STATED HE HAS NOT SLEPT FOR 3 WEEKS CE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I HIS CPAP MACHINE AND IT WILL BE GIVEN TO Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology, OBJECTIVE: Pulse: Date lima Rate Per Minute Location 07/30/2019 13:02 94 07/30/2019 09:40 88 Via Machine 07/30/2019 09:30 87 Via Machine Respirations: Date Time Rate Per Minute Provider 07/30/2019 09:30 NYM 12 Blood Pressure: d Respiratory Date Lime Value Location Position 07/30/2019 13:02 NYM 114/84 Loft Arm Standing 07/30/2019 09:40 NYM 125/60 Right Arm Standing 07/30/2019 09:30 NYM 108/86 Loft Arm Sitting Cuff Size. Provider SaO2: jay Time Value170). Aft expvider 07/30/2019 09:30 NYM 98 Room Air Woight: awe Time L§A Kg Waist Circum Provider Generated 07/30/2019 14.05 by Buroau of Prisons • NYM Page 1 of 3 | Kg Weisireirsaira. Provider
Lka
Time
Date
88.1
194.2
09:30 NYM
07,30/2019
General
Affect
Yes: Cooperative
Appearance
Yes: Appears Well, Alert and Oriented x 3
ed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic.
No: Appears Distre
Disheveled, Unkeai ' p cutely III
•
Nutrition
No: Appears O
Pulmonary
Auscultation
Yes: Clear to Auscultation
Cardiovascular
Auscultation
1 and S2
Yes: Regular Rate and Rhythm (RRR
No: MJR/G
Musculoskeletal
Tibia / Fibula
No: Edema
Neurologic
Cranial Nerves (CN)
Yes: Within Normal Limits
Motor System-General
Yes: Normal Exam
Motor System-Strength
Yes: Normal Muscular Strength
ASSESSMENT:
Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current
Constipation, unspecified, K5900 - Current
Essential (primary) hypertension, 110 - 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:
prescriber Order
Order Date
Medication
Rx# | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/30/2019 11:12 | M
Sex:
Provider: | Race: WHITE | Reg ft
Facility: NYM
Unit: | 76318.054
Z01 | | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------ | ------------------------------------------------------------------------- | ---------------------- | ----------- | -------------------------------- | ---------------- | | | | | | | | | | | Exam: | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/30/2019 11:12 | Sex:
Provider: | | Reg ti:
Unit: | 76318-054
Facility: NYM
201 | | | ----------------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------ | -------------------------------- | --------------------------- | ---------------------------------------------------------------------- | -------------------------------------- | | Now Medication Orders: | | | | | | | | | Medication
Magnesium Hydroxide Susp conc 800
MG/5ML | | Order Date
07/30/2019 11:12 | | Prescriber Order
Day PRN x 90 day(s) | 10 CC Orally - Two Times a | | | Indication: Constipation, unspecified
INsulin REG - Human | | 07/30/2019 11:12 | | SLIDING SCALE
Day x 7 day(s) Pill Line Only | Subcutaneously - Two Times a | | | Indication: Prediabetes | | | | | | | Renew Medication Orders: | | | | | | | | 121836-NYM | Medication
o ne 4 MG Tab ( 21 count
methylPR
Pack)
Indication: | is and neuritis, unspecified | \_Order ctate
07/30/2019 11:12 | | Prescriber Order
Take the tablet by mouth as
directed x 6 day(s) | | | New Laboratory Requests:
Details | Lab Tests - Short List-General-CBC w/diff
Lab Tests-P-PSA, Total
Lab Tests-U-Uric Acid
Lab Tests - Short List-General-Comprehensiv | Frequency
ne Time | | Du Date
08/01/2019 00:00 | | Priority
Routine | | Details | Metabolic Profile (CMP)
Lab Tests-U-Urinalysis w/Reflex to Microscopic
New Radiology Request Orders: | Frequency | | Due Date | | jei 2Qiy | | General | General Radiology-Spine / Cervical-
Specific reason(s) for request (Complaints and findings):
66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI
PLEASE PERFORM C SPINE SERIES | One Time | | 08/29/2019 | R 2-3 MINUTES 3 DAYS AGO. | Routine | | | | | | | | | | Disposition: | Follow-up at Sick Call as Needed | | | | | | | Patient Education Topics: | | | | | | | | 07/30/2019 | Date InitiatedFormat
Counseling | aansigi,daggic
Access to Care | | | | asgsome
Verbalizes
Understanding | | 07/30/2019 | Counseling | Plan of Care | | | | Verbalizes
Understanding | | Copay Required:No
TelophoneNerbal Order:
Completed by | No | Cosign Required: No
on 07/30/2019 14:05 | | | | | | | | | | | | | | Generated 07/30/2019 14:05 by | | | Bureau of Prisons • NMI | | | Page 3 of 3 | # Bureau of Prisons Health Services | Health
Clinical | Services
Encounter | | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | | EPSTEIN, JEFFREY EDWARD
Inmate Name:
Sex:
01/20/1953
Date of Birth:
Encounter Date: 07/30/2019 11:12
Provider: | 76318.054
Reg #:
Facility: NYM
Z01
Unit: | | Chronic Care - Chronic Care Clinic encounter performed al Health Services. | | | SUBJECTIVE: | | | Provider:
COMPLAINT 1 | | | Chief Complaint: Other Problem | | | 3,eS
PATIENT s
Subjective:
PATIEN
STATES)
HE DENI
OWING.
SPEAKING
HE REPORT
HE REPORTS H
TOPROL.
HE AHS A HX OF SLEE_PAp
ISNCE HE HASB EEN HER
INFORME DHIM THAT WE R
HIM TONIGHT
HE REPORT OTHER NON-MEt51CAIPISS.UES. | ' REFERRED BY THE WARDEN FOR EVALUATION.
rigERORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE
ALSO AE 15(fR;TS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO.
BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING.
SIDED WEAKNESS, DIPLOPIA. FACIAL DROOP, DIFFICULTY
IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA.
DNEY STONES. FIX OF HTN FOR WHICH HE WAS TAKING
AND STATED HE HAS NOT SLEPT FOR 3 WEEKS
CE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I
El1LED HIS CPAP MACHINE AND IT WILL BE GIVEN TO | | STATES HE FEELS OTHERWISE
Pain:
Not Applicable | | | Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rhoumatology, | espiratory | | | 7) | | OBJECTIVE: | | | Pulse:
Location
Rate Per Minute | Provider | | 94
07/30/2019 13:02 | | | 88
07/30/2019 09:40 | Via Machine | | 87
07/30/2019 09:30 | Via Machine | | | | | Respirations:
Rate Per Minute. ELovider
Time
bets | | | 12
09:30 NYM
07/30/2019 | | | Blood Pressure: | | | value
Location
i
e
i2.8 1e
Left Arm
114/84
07/30/2019 13:02 NYM | Pr eider
Cuff Size
Position
Standing | | Right Arm
125/60
07/30/2019 09:40 NYM | Standing | | Left Arm
108/86
07/30/2019 09:30 NYM | Silting | | SaO2: | | | Time
Valuel%1
Aft
Qata
98 Room Air
09:30 NYM
07/30/2019 | Provider | | Weight: | | | Time
Lk
pats | Kg Waist Circuni, Proviskr. | | Generated 07/30/2019 14:05 by | Page 1 of 3
Bureau of Prisons • NYM | | Inmate Name:
Date of Birth:
Encounter Date: 07/30/2019 11:12 | EPSTEIN, JEFFREY EDWARD
01/20/1953 | | Sex:
Provider: | | Reg fi:
Facility: NYM
201
Unit: | 76318-054 | | ------------------------------------------------------------------ | --------------------------------------------------------- | --------------- | --------------------------- | ------------------------------------------------------------------------------------- | ---------------------------------------- | --------- | | Date
07/30/2019 | Time
09:30 NYM | 1.128.
194.2 | Waist Circiunt
K
88.1 | Provider | | | | Exam:
General | | | | | | | | Affect | | | | | | | | | Yes: Cooperative | | | | | | | Appearance | | | | | | | | | Yes: Appears Well, Alert and Oriented x 3 | | | | | | | Nutrition | No: Appears Distre
Disheveled, Unke | cutely III | | ed, Dyspneic. Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic. | | | | | No: Appears Obi | | | | | | | Pulmonary | | | | | | | | Auscultation | Yes: Clear to Auscultation | | | | | | | Cardiovascular | | | | | | | | Auscultation | | | | | | | | | Yes: Regular Rate and Rhythm (RRR | | it4 | loand S2 | | | | | No: M/R/G | | | | | | | Musculoskeletal | | | | | | | | Tibia / Fibula | | | | | | | | | No: Edema | | | | | | | Neurologic | Cranial Nerves (CN) | | | | | | | | Yes: Within Normal Limits | | | | | | | | Motor System-General | | | | | | | | Yes: Normal Exam | | | | | | | | Motor System-Strength | | | | | | | | Yes: Normal Muscular Strength | | | | | | | ASSESSMENT: | | | | | | | | | Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current | | | | | | | | Constipation, unspecified. K5900 - Current | | | | | | | | Essential (primary) hypertension, 110 - Current - BY FIX. | | | | | | | | 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:
IlmA | Medication | | | Order Data | Proscriber Order | | | | | | | | | | | Inmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Dale: 07/30/2019 11:12 | Sox:
Provider: | ii•Rsai | s | Reg II:
Unit: | 76318.054
NYM
201 | | | -------------------------------------------- | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ----------------------------------------------------- | ------------------------------ | ---------------------------- | ---------------- | --------------------------------------- | ------------------------------------------------------------- | | | | | | | | | | | New Medication Orders: | | | | | | Prescriber Order | | | Bag | JYtedication
Magnesium Hydroxide Susp conc 800
MG/5ML | | Order Date
07/30/2019 11:12 | | | Day PRN x 90 day(s) | 10 CC Orally - Two Times a | | | 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 | | | | | | | | Renew Medication Orders: | | | | | | | | | fixft
121836-NYM | Medication
methylPR
Pack)
Indication: | ne 4 MG Tab ( 21 count
a and neuritis. unspecified | Order Dfin
07/30/2019 11:12 | | | prescriber Order
directed x 6 day(s) | Take the tablet by mouth as | | New Laboratory Requests: | | | | | | | | | Details | Lab Tests - Short List-General-CBC w dill
Lab Tests-P-PSA, Total
Lab Tests-U-Uric Acid
Lab Tests - Short List-General-Comprehensiv
Metabolic Profile (CMP)
Lab Tests-U-Urinalysis w/Rellex to Microscopic
New Radiology Request Orders: | Frequency
2 ne Time | | Due Date
08/01/2019 00:00 | | Priority
Routine | | | | | Frequency | | Due Date | | | Priori | | Details
General | General Radiology-Spine / Cervical- | One Time | | | 08/29/2019 | | Routine | | | Specific reason(s) for request (Complaints and findings): | | | | | | | | | 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI
PLEASE PERFORM C SPINE SERIES | | | | | | R 2-3 MINUTES 3 DAYS AGO. | | Disposition: | | | | | | | | | | Follow-up at Sick Call as Needed | | | | | | | | Patient Education Topics: | | | | | | | | | 07/30/2019 | Date Initiated Format
Counseling | Handout/Topic
Access to Care | | | | | Outcome
Verbalizes
Understanding | | 07/30/2019 | Counseling | Plan of Care | | | | | Verbalizes
Understanding | | Copay Required: No
TelophoneNerbal Order: | No | Cosign Required: No | | | | | | | Completed by | | on 07/30/2019 14:05 | | | | | | | | | | | | | | | | Generated 07:302019 14:05 by | | | Bureau of Prisons NYM | | | | Page 3 of 3 | | | | | | | | | | | | | | | | | | | | of
Prisons
Bureau
Services
Health
Amendment
See | | | | | | | | ----------------------------------------------------------------- | ------------------------------------------------------------------------- | ---- | ----------------------- | ---------------------------- | ---------------------- | --- | | Irmate Name:
Date of Birth: | EPSTEIN, JEFFREY EDWARD
01/20/1953
Encounter Date: 07/30/2019 15:58 | Sex: | M | Reg #:
Race:
Facility: | 54
7631
WH
NY | | | | Amendment made to this note by | | on 07/30/2019 16:12. | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Borneo of Prisons - NYM | | | | | | | | | | | |