Draft: efta00105002

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¶

¶

¶

¶

Generaled 08/10/2019 11:02 by Bureau or Prisons • NYM Pigs 3d 3¶

Bureau of Prisons Health Services¶

PPDs¶

¶

Generated 08/10/2019 11:02 by illnOP/IDC Bureau of Prisons - NYM Page 1 of I¶

31 8-0 54 76	RE Y ST EIN JE FF EP ,		M	d e	i c a	i t o	n	A d	i m	i n	t s r	i t a	n o	R	e c	o r	d								JU LY	2	01 9
	ed ica tio de M Or n rs	Ti m e	1	2	3	4	5	6	7	8	9	10	1 1	12	1 3	14	1 5	16	1 7	18	1 9	20	2 1	22	2 3	24	2 5	26	2 7	28	2 9	30	1 3
Ord . Da to 07/ 30/ 19 14 21	ly p ula r In lln wb hde c1 r cut au nn oo ua er eg	PR N
b) Ex Da p. 31/ 07/ 19 10: 01	NO t" lor 7 cab x W eke da y " lin ellr En g e - da n
MA A 1U 141 3- M NY	Mj MI k) 10 0 ~ KN Re (10 I. g
Oc t D ate 07/ 31/ 19 90	ly p bla d n tas ten ba tar nn ea us	PR N
10 agu au ar 0 st- la: ch rnl 7 d alld beg tor ay- au ma mo ng De le Es p. 08/ 07, 19 09 59
rlY Al 122 160 - NY M	S/9 /1 N j /Q ) 10 0 U NIT Lns u'-n Ro (10 g

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JE FF RE Y : E PS YE IN. Na 8-0 54 n W 76 31 urn Re isw ato g	12 d5 3 01 DO B: 2 E ST 8/1 00 01 9 1 1:0 of int ing : 0 d O f lh e d ato n is nta nt a pr rt In an ma Re ton s o na go co po

76318-054 Ord. Moo 07/31/19 1000 Exp. Dto 01/07/19 09$3 NYRE 122100. Nria EPSTEIN, JEFFREY Medication Orders Irgsal regular Ins uUn subcutaneously pot slIdIng scale: each ', iming for 7 days "'pig Ens"' LR.Lein Rog (10 MO 100 UNITS/PAL In) Medication Administration Record AUGUST 2019 Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 PAN¶

Pr da
Ce O Or Do No In d ica d de R D e de I M t te Do tio c s: r se cu me aa n
Pt. Na : E PS TE IN. JE F-F liEr Y Re tio n P . 7 63 18- 05 4 tra me gs	DO B /20 /53 01 ES T /10 /20 11 :02 08 19 of d tim f p rin tin Re t the da te rt in for n it an e o g: po an en a rna go

Bureau of Prisons Health Services¶

Devices and Equipment¶

Start Date: #: 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¶

¶

4 7 6 3 1 8- 0 5 Re #: g	F F R E Y E D P S T E I N, J E Na E In te e: m a m	W A R D
T i p c s o
d In it iat D ate e	H do To ic F it ut an n	O tc om e u	de Pr i r ov
On En g	E S T / / 2 0 1 9 1 3: 3 3 red 0 7 1 2 te :
To l: 1 0 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¶

¶

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¶

¶

¶

••• 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 0 7 3 1 2 0 — 32 31	0 10 11 12 13 14 15 16 0 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 On D'i) Ce SS/ -VAor Let--)-e—r c,--	setv-c• • Cerrociim	I 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 i s-kin t -	E g:P t -.e y - _	Den ' • •
ay Number: nu ;VC- OS-1 -7( ,	Institution: YORK MCC NE	Date: 9 7 -1 - 2-6	nature Block/ •	tamp: •
			et en a MCC New Yor	cer 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

¶

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:

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