Bureau of Prisons

Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 08/10/2019 07:25 Provider: RN Unit: Z04 Emergency Code - Resuscitation Event encounter performed at Special Housing Unit. SUBJECTIVE: Emergency Note Provider: Team Members: Provider RN Bole Team/Code Leader RN Code Events: IYRe Value Date 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 ET Tube 7.5 24CM to L Lip line Placed by Paramedics 08/10/2019 07:08 Medications Epinephrine 1mg IV 08/10/2019 07:10 Epinephrine 3 doses and Sodium bicarb 2 doses administered by paramedics CPR Compressions 08/10/2019 07:11 Medications Sodium Bicarbonate 1 mEa/kg IV 08/10/2019 07:11 IV Fluids Normal Saline 0.9% 1000 ml 08/10/2019 07:12 Medications Epinephrine 1mg IV 08/10/2019 07:13 CPR Compressions 08/10/2019 07:14 Medications Sodium Bicarbonate 1 mEa/kg IV 08/10/2019 07:14 Medications Epinephrine 1mg IV 08/10/2019 07:16 CPR Compressions 08/10/2019 07:17 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, Call 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, O2 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 08/1012019 08:10 by RN Bureau of Prisons - NYM SDNY_0001:74564 1 of 2 EFTA00138991 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 08/10/2019 07:25 Provider: RN Unit: Z04 Exam: ASSESSMENT: Cardiac Arrest PLAN: New Consultation Requests: Consultation/Procedure Target Date Scheduled Target Date Priority Translator Language Emergency Room 08/10/2019 08/10/2019 Emergent No Subtype: AMBULANCE Reason for Request: Cardiac arrest with CPR in progress Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Completed by RN on 08/10/2019 08:10 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 08,10,2019 08:10 by RN Bureau of Prisons - NYM SDNY_0001-71.55 rage 201 2 EFTA00138992 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 08/10/2019 07:25 Provider: RN Facility: NYM Cosigned by MD on 08/12x2019 08:09. Bureau of Pesons NYM SDNV_00017356 EFTA00138993 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 15:58 Provider: MD Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: MD Chief Complaint: Other Problem Subjective: PATIENT WAS REFERRED BY THE WARDEN FOR EVALUATION. PATIENT REPORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO REPORTS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STATES THE NUMBNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. HE DENIES RIGHT SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OR SWALLOWING. HE REPORTS NOCTURIA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. HE REPORTS H OF KIDNEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEP APNEA AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HERE SINCE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE RECEIVED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-MEDICAL ISSUES. STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Seen for clinic(s): Pulmonary/Respiratory, Orthopedic/Rheumatology, Endocrine/Lipid OBJECTIVE: Exam: General Affect Yes: Cooperative 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 Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2 No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neurologic Generated 07/30/2019 16:12 by MD Bureau of Prisons - NYM SONY_0001-7257 raga 1 of 2 EFTA00138994 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 15:58 Provider: MD Reg #: 76318-054 Facility: NYM Unit: Z01 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. 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: Eta Medication INsulin REG - Human Indication: Prediabetes Discontinued Medication Orders: Eta Medication 122148-NYM Insulin Reg (10 ML) 100 UNITS/ML lnj Order Date 07/30/2019 15:58 Order Date 07/30/2019 15:58 Discontinue Type: When Pharmacy Processes Discontinue Reason:new order written Indication: Copay Required:No Telephone/Verbal Order: No Completed by Cosign Required: No MD on 07/30/2019 16:12 Prescriber Order SLIDING SCALE Subcutaneously each morning x 7 day(s) Pill Line Only Prescriber Order Inject regular insulin subcutaneously per sliding scale: twice daily —*pill linen* for 7 days SDNY Generated 071302019 16:12 by _000 MD Bureau of Prisons - NYM 1102 of 2 EFTA00138995 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 11:12 Provider: MD Reg #: 76318-054 Facility: NYM Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT PATIE ALS STAT HE DEN SPEAKING HE REPORT HE REPORTS TOPROL. HE AHS A HX OF SLEEP ISNCE HE HASB EEN INFORME DHIM THAT WE HIM TONIGHT.. HE REPORT OTHER NON-ME STATES HE FEELS OTHERWISE Pain: Not Applicable MD REFERRED BY THE WARDEN FOR EVALUATION. RTS HE HAS BEEN WITHOUT HIS MEDS 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. NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING AND STATED HE HAS NOT SLEPT FOR 3 WEEKS E HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I HIS CPAP MACHINE AND IT WILL BE GIVEN TO ES. OBJECTIVE: Pulse: Date Time 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 07/30/2019 09:30 NYM Rate Per Minute Provider 12 Blood Pressure: Date Time Value Location Position 07/30/2019 13:02 NYM 114/84 Left Arm Standing 07/30/2019 09:40 NYM 125/60 Right Arm Standing 07/30/2019 09:30 NYM 108/86 Left Arm Sitting SaO2: Date Time Value(%) Air 07/30/2019 09:30 NYM 98 Room Air Weight: Date Time )1 Cuff Size Provider Provider Lim Kg Waist Circum Provider MD D MD MD MD Generated 07/30/2019 14:05 by MD Bureau of Prisons - NYM SDNY_0001/01 of 3 Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology,4 Respiratory EFTA00138996 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 11:12 Provider: M Race: WHITE Reg #: 76318-054 Facility: NYM MD Unit: Z01 Date lime 07/30/2019 09:30 NYM 194.2 88.1 MD Lbs Kg Waist Circum. Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distr ed. Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unk cutely III Nutrition No: Appears O Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR 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 HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, 87303 - Current Sleep apnea, G4730 - Current 1 and S2 PLAN: New Medication Orders: BXg Medication Order Date Prescriber Order 2 of 3 Generated 07)30,2019 14:05 by MD Bureau of Prisons - NYM SDNY_OOOWN EFTA00138997 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 11:12 Provider: MD Reg #: 76318-054 Facility: NYM Unit: Z01 New Medication Orders: fiat Medication Order Date Magnesium Hydroxide Susp conc 800 07/30/2019 11:12 MG/5ML Indication: Constipation, unspecified INsulin REG - Human 07/30/2019 11:12 Indication: Renew Medication Orders: Medication 121836-NYM methylP Pack) Indication: New Laboratory Requests: Details Frequency Lab Tests - Short List-General-CBC w diff one Time Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short List-General•Comprehensiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic New Radiology Request Orders: Details General Radiology-Spine / Cervical- General Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NU PLEASE PERFORM C SPINE SERIES Prediabetes Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format 07/30/2019 Counseling 07/30/2019 Counseling Copay Required:No Telephone/Verbal Order: No Completed by ne 4 MG Tab ( 21 count Order Date 07/30/2019 11:12 a and neuritis, unspecified Frequency One Time Handout/Topic Access to Care Plan of Care Cosign Required: No MD on 07/30/2019 14:05 Prescriber Order 10 CC Orally • Two Times a Day PRN x 90 day(s) SLIDING SCALE Subcutaneously • Two Times a Day x 7 day(s) Pill Line Only Prescriber Order Take the tablet by mouth as directed x 6 day(s) Due Date 08/01/2019 00:00 Due Date 08/29/2019 Priority Routine Priority Routine R 2-3 MINUTES 3 DAYS AGO. Outcome Verbalizes Understanding Verbalizes Understanding Generated 071302019 14:05 by MD Bureau of Prisons - NYM SDNY_00011613 of 3 EFTA00138998 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 11:12 Provider: MD Reg #: 76318-054 Facility: NYM Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT PATIE ALS STAT HE DEN SPEAKING HE REPORT HE REPORTS TOPROL. HE AHS A HX OF SLEEP ISNCE HE HASB EEN INFORME DHIM THAT WE HIM TONIGHT.. HE REPORT OTHER NON-ME STATES HE FEELS OTHERWISE Pain: Not Applicable MD REFERRED BY THE WARDEN FOR EVALUATION. RTS HE HAS BEEN WITHOUT HIS MEDS 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. NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING AND STATED HE HAS NOT SLEPT FOR 3 WEEKS E HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I HIS CPAP MACHINE AND IT WILL BE GIVEN TO ES. Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology0 Respiratory 0 OBJECTIVE: Pulse: Date lime 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 07/30/2019 09:30 NYM Rate Per Minute Provider 12 Blood Pressure: Data lime Value Location Position 07/30/2019 13:02 NYM 114/84 Left Arm Standing 07/30/2019 09:40 NYM 125/60 Right Arm Standing 07/30/2019 09:30 NYM 108/86 Left Arm Sitting SaO2: Data lima 07/30/2019 09:30 NYM Weight: Date Time Cuff Size Provider Value(%) Air Provider 98 Room Air Lin Kg Waist Circum. Provider MD MD MD MD MD MD MD Generated 071302019 14:05 by MD Bureau of Prisons - NYM SDNY_0001-7382 rage-1 of 3 EFTA00138999 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 11:12 Provider: M Race: WHITE Reg #: 76318-054 Facility: NYM MD Unit: Z01 Date Time 07/30/2019 09:30 NYM 194.2 88.1 MD Lbs Kg Waist Circum. Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distr ed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unk cutely III Nutrition No: Appears O Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR 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 HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, 87303 - Current Sleep apnea, G4730 - Current 1 and S2 PLAN: New Medication Orders: Hxg Medication Order Date Prescriber Order Generated 07/3012019 14:05 by MD Bureau of Prisons - NYM SDNY_0001-7383 rage 2 of 3 EFTA00139000 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 11:12 Provider: MD Reg #: 76318-054 Facility: NYM Unit: Z01 New Medication Orders: fiat Medication Order Date Magnesium Hydroxide Susp conc 800 07/30/2019 11:12 MG/5ML Indication: Constipation, unspecified INsulin REG - Human 07/30/2019 11:12 Indication: Renew Medication Orders: 13att Medication 121836-NYM methylP Pack) Indication: New Laboratory Requests: Details Frequency Lab Tests - Short List-General-CBC w diff one Time Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short List-General•Comprehensiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic New Radiology Request Orders: Details General Radiology-Spine / Cervical- General Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NU PLEASE PERFORM C SPINE SERIES Prediabetes Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format 07/30/2019 Counseling 07/30/2019 Counseling Copay Required:No Telephone/Verbal Order: No Completed by ne 4 MG Tab ( 21 count Order Date 07/30/2019 11:12 a and neuritis, unspecified Frequency One Time Handout/Topic Access to Care Plan of Care Cosign Required: No MD on 07/30/2019 14:05 Prescriber Order 10 CC Orally • Two Times a Day PRN x 90 day(s) SLIDING SCALE Subcutaneously • Two Times a Day x 7 day(s) Pill Line Only Prescriber Order Take the tablet by mouth as directed x 6 day(s) Due Date 08/01/2019 00:00 Due Date 08/29/2019 Priority Routine Priority Routine R 2-3 MINUTES 3 DAYS AGO. Outcome Verbalizes Understanding Verbalizes Understanding Generated 072302019 14:05 by MD Bureau of Prisons - NYM SDNY_000a3 of 3 EFTA00139001 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 15:58 Facility: NYM Amendment made to this note by MD on 07 30 2019 16:12. Bureau of Prisons • NYM SDNY_00017365 EFTA00139002 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/28/2019 20:25 Provider: RN Unit: H01 Nursing - Follow up encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: RN Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies) Subjective: Inmate seen for F/U after returning from attorney conference offers no new complaints or worsening S/S stats " My R hand still has pins and needles sometimes" No change in appearance from previous exam. Pain: No OBJECTIVE: Pulse: Date lime Rate Per Minute Location Rhythm Provider 07/28/2019 20:28 81 RN Respirations: Dale Time Rate Per Minute Provider 07/28/2019 20:28 NYM 14 RN Blood Pressure: Date lime Value Location Position Cuff Size Provider 07/28/2019 20:28 NYM 157/91 RN SaO2: Dale BEM Valuer/O1 Air Provider 07/28/2019 20:28 NYM 98 RN 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 RN Bureau of Prisons - NYM SDNY_000W1 of 2 EFTA00139003 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/28/2019 20:25 Provider: RN Unit: H01 Follow-up in 12-24 Hours Patient Education Topics: Date Initiated Format Handout/Topic 07/28/2019 Counseling Plan of Care Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Completed by RN on 07'28'2019 20:30 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Provider Outcome Verbalizes Understanding Generated 0712&201920:30 by RN Bureau of Prisons - NYM SDNY_0001-7387 rage 2 of 2 EFTA00139004 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/28/2019 20:25 Provider: RN Facility: NYM Cosigned by MD on 07 28 2019 20:50. ' Pr ',or, NYt! SDNV_00017368 EFTA00139005 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: RN Unit: H01 Nursing - Triage Note encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: RN Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies) Subjective: " I woke up and I had no control over my Right arm for a few minutes it was just doing what it wanted to do" Pain: No OBJECTIVE: Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/28/2019 06:57 82 RN Respirations: Date Time Rate Per Minute Provider 07/28/2019 06:57 NYM 14 RN Blood Pressure: Date lime Value Location Position Cuff Size Provider 07/28/2019 06:57 NYM 138/80 SaO2: Date Time Valuerkl Air 07/28/2019 06:57 NYM 98 Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 Skin General Yes: Within Normal Limits, Dry, Skin Intact provider 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 RN RN Face General Yes: Symmetric Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM SDNY_00011491 of 3 EFTA00139006 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: RN Unit: H01 Exam: No: Ecchymosis, Numbness, Swelling, Periorbital Edema Neck General Yes: Abrasion(s) Pulmonary Observation/Inspection Yes: Within Normal Limits No: Respiratory Distress, Tachypnea, Hyperventilation Cardiovascular Observation Yes: Normal Rate Musculoskeletal Shoulder Yes: Full Range of Motion R, Symmetric R No: Swelling R, Inflammation R Humerus Yes: Within Normal Limits R Elbow Yes: Normal Exam R, Full Range of Motion R, Non-Tender on Palpation R Radius / Ulna Yes: Normal Exam R, Full Range of Motion R WrisVHand/Fingers Yes: Full Range of Motion R, Non-Tender on Palpation R, Swelling R No: Inflammation R, Ecchymosis R, Erythema R, Tenderness R, Laceration(s) R, Abrasion(s) R, Contusion(s) R ROS Comments Received inmate AAOX3 in no acute distress, speaking in full sentenced ambulating independently CIO Right arm numbness after waking up from "sleeping on my side" 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 tingling at this time. Denies any Chest pain, Headache, Dizziness, SOB or Blurred vision. Eyes PERRLA. MD on Call notified, Re-evaluate this evening or sooner if S/S persist. ASSESSMENT: Alteration in comfort PLAN: Disposition: Follow-up at Sick Call as Needed Notify Medical Duty Officer Patient Education Topics: Date Initiated Format Handout/Topic Provider Outcome 07/28/2019 Counseling Plan of Care Verbalizes Understanding Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM SDNY_0001:7422 of 3 EFTA00139007 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: RN Unit: H01 Date Initiated Format HandouUTqpic Provider Outcome Copay Required:No Telephone/Verbal Order: No Completed by RN on 07/28/2019 07:22 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Cosign Required: Yes Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM SDNY_000'1:7413 of 3 EFTA00139008 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/28/2019 06:51 Provider: RN Facility: NYM Cosigned by MD on 07.28.2019 20:51. ' Pr sae; NYt.' SDNV_00017372 EFTA00139009 Copay Required:No Telephone/Verbal Order: No Completed by Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: Date of Birth: Note Date: EPSTEIN. JEFFREY EDWARD 01/20/1953 07/26/2019 08:57 Sex: Provider: M MD Reg #: Facility: Unit: 76318-054 NYM H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. New Medication Orders: SX Medication Docusate Sodium Capsule Indication: Constipation, unspecified Cosign Required: No MD on 07/26/2019 08:58 Order Date 07/26/2019 08:57 Prescriber Order TAKE ONE 100 MG CAP Orally - Two Times a Day x 180 day(s) Generated 07.262019 08:58 by MD Bureau of Prisons - NYM SDNY_OOPOW1)3°I EFTA00139010 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: • Facility: NYM Note Date: 07/24/2019 16:10 Provider: MD Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. Copay Required:No Telephone/Verbal Order: Completed by Cosign Required: No 24/2019 16:12 Generated 07/24/2919 16:12 by MD Bureau of Prisons - NYM soNcooPoiVe EFTA00139011 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Rarp.WHITF Note Date: 07/24/2019 16:10 Provider: Reg #: 76318-054 Facility: NYM MD Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. Copay Required:No TelephoneNerbal Order: Completed by I Cosign Required: No 24/2019 16:12 Generated 07/24/2919 16:12 by MD Bureau of Prisons - NYM SDNY_OOPOWe f 1 EFTA00139012 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/26/2019 08:57 Facility: NYM Amendment made to this note by MD on 07 26 2019 08:58. Bureau of Prisons • Nym SDNY_00017376 EFTA00139013 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Facility: NYM Note Date: 07/24/2019 15:10 Provider: 1WISM MD Unit: H01 Admin Note - General Administrative Note encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD PATIENT WAS OFFERED TO HAVE AN OPTOMETRIST EVALUATION. HE REFUSED. REFUSAL FORM SIGNED. Copay Required:No TelephoneNerbal Order: No Completed by Cosign Required: No MD on 07/24/2019 15:17 Generated 07/24/2919 15:17 by MD Bureau of Prisons - NYM SDNY_OOPOWV7°f 1 EFTA00139014 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/24/2019 13:08 Provider: MLP Unit: H01 Mid Level Provider - Follow up Visit encounter performed at Receiving & Discharge. SUBJECTIVE: COMPLAINT 1 Provider: . MLP Chief Complaint: Other Problem Subjective: I still do not want to talk about. But, between you and me. I think my room mate had to do with what happened to me. Do not ask me. I am not going to say anything. Pain: No OBJECTIVE: Temperature: Date Time Fahrenheit Celsius Location Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral MLP Pulse: Dale Time Rate Per Minute Location Rhythm Provider 07/24/2019 13:12 83 Via Machine Regular . MLP Blood Pressure: Date Time Maim Location Position Cuff Size Provider 07/24/2019 13:12 NYM 132/89 Right Arm Sitting Adult-regular MLP SaO2: Date Time Value(%) Ai_► Provider 07/24/2019 13:12 NYM 96 Room Air MLP 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 does not complaint of any respiratory problem or distress. He still does not want to explain how the skin injury on his neck happed. 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: Generated 07/24/2019 13:24 by MLP Bureau of Prisons - NYM SDNY_0001-7379 raya 1 of 2 EFTA00139015 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/24/2019 13:08 Provider: . MLP Unit: H01 Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format Handout/Topic ii. Outcome 07/24/2019 Counseling Access to Care . Verbalizes Understanding 07/24/2019 Counseling Preventive Health Verbalizes Understanding Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Completed by . MLP on 07/24/2019 13:24 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. SDNY Generated 07124/2019 13:24 by _0001-7379 MLP Bureau of Prisons - NYM raga 92 of 2 EFTA00139016 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/24/2019 13:08 Provider: MLP Facility: NYM Cosigned with New Encounter Note by MD on 07/24/2019 16:10. Bureau of Prisons NYM SDNY_00017380 EFTA00139017 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: MLP Unit: H01 Injury Assessment - Non-work related encounter performed at Health Services. SUBJECTIVE: INJURY 1 Provider: MLP Date of Injury: 07/23/2019 01:27 Date Reported for Treatment: 07/23/2019 08:25 Work Related: No Work Assignment: UNASSG Pain Location: Pain Scale: 0 Pain Qualities: Where Did Injury Happen (Be specific as to location): Special Housing Unit Z05-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: Data Time Fahrenheit Celsius Location 07/23/2019 06:30 NYM 97.5 36.4 Oral Provider MLP Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/23/2019 06:30 92 Via Machine Regular . MLP Respirations: Data Time Rate Per Minute Provider 07/23/2019 06:30 NYM 16 MLP Blood Pressure: Data Time Value Location Position Cuff Size Provider 07/23/2019 06:30 NYM 140/85 Right Arm Sitting Adult-regular MLP SaO2: Date Time Value(%) Air Provider 07/23/2019 06:30 NYM 96 Room Air MLP 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, Generated 071231201909:05 by MLP Bureau of Prisons - NYM SDNY_0001-7391 raga 1 of 2 EFTA00139018 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: . MLP Unit: H01 Exam: Acutely III Pulmonary Auscultation Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally No: Crackles, Rhonchi, Wheezing Exam Comments Inmate for injury report as requested by Operational Lt. He is ambulatory, oriented x 3. In not apparent distress, smiling during this clinical encounter. Alleges, that he does not 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 inches wide, sparing 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 without any 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 and sitting on the floor. Inmate is currently placed on suicide watch. ASSESSMENT: Injury, unspecified, T1490 - Current - R/O self inflicted injuries. 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: Date Initiated Format Handout/Topic MI. Outcome 07/23/2019 Counseling Access to Care Verbalizes Understanding 07/23/2019 Counseling Plan of Care Verbalizes Understanding Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Completed by . MLP on 07/23/2019 09:05 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 07123 201909.05 by MLP Bureau of Prisons - NYM SDNY_0001-739 ag2 re -2 of 2 EFTA00139019 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/23/2019 06:20 Provider: MLP Facility: NYM Cosigned by MD on 07/23/2019 15:44. Bureau of Prisons NYM SDNY_00017383 EFTA00139020 Bureau of Prisons Health Services Clinical Encounter 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: MD Unit: Z05 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: MD Chief Complaint: ENDO/LIPID Subjective: 66 YR OLD WHITE MALE WITH HX OF HYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , NOW 431. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS DUE TO THEIR GI SIDE EFFECTS. HX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE FBI LOKELY HAS L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES. SURGICAL HX: NONE MENTAL HEALTH HX: NONE 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): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid Added to clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid 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 Generated 07/14/2019 18:11 by MD Bureau of Prisons - NYM SDNY_00011464 1 of 3 EFTA00139021 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Ar il ivr/lHITE Encounter Date: 07/14/2019 17:36 Provider: MD Reg #: 76318-054 Facility: NYM Unit: Z05 Exam: Eyes General Yes: PERRLA, Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR), Normal St and S2 No: M/R/G Abdomen 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: JIM Medication Omega 3 ( Vascepa) 1 GM Capsule Order Date 07/14/2019 17:36 Indication: Hyperlipidemia, unspecified New Laboratory Requests: Details Frequency Lab Tests-H-Hemoglobin A1C One Time Lab Tests-L-Lipid Profile Additional Information: Generated 07/14;2019 18:11 by MD Bureau of Prisons - NYM Prescriber Order TAKE 2 CAPS Orally - Two Times a Day x 180 day(s) -- TAKE WITH FOOD. Due Date Priority 10/10/2019 00:00 Routine SDNY_00047rog 18852 of 3 EFTA00139022 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Reg #: Facility: 76318-054 NYM Encounter Date: 07/14/2019 17:36 Provider: MD Unit: 205 FASTING. Lab Tests-H-Hep B surface Ab One Time 08/08/2019 00:00 Routine Lab Tests-H-Hep B surface Ag Lab Tests-H-Hep C Ab Lab Tests-H-Hepatic Profile Schedule: Activity Date Scheduled Clinical Encounter 07/24/2019 00:00 66 YR OLD MALE FOR ROUTINE SCREENING. Chronic Care Visit 01/07/2020 00:00 6 MONTH F/U. Chronic Care Visit 07/01/2020 00:00 Other: PENDING EKG AND FOBT. CXR WAS REFUSED. Patient Education Topics: Date Initiated Format 07/14/2019 Counseling Copay Required:No Telephone/Verbal Order: No Completed by Handout/Topic Diagnosis Cosign Required: No MD on 07/14/2019 18:11 Scheduled Provider Optometrist Mid-Level Provider Physician 01 Provider Outcome Verbalizes Understanding Generated 07/14/2019 18:11 by MD Bureau of Prisons - NYM SDNY_000R193 of 3 EFTA00139023 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: Z05 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDO/LIPID Subjective: 66 YR O HITE MALE WITH HX OF HYPER CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MED • EIR GI SIDE EFFECTS. HX OF 4L UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES TH Y HAS L4 - L5 SEVERE iSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREM SURGICAL HX: NONE MENTAL HEALTH HX: 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: MD 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 Generated 07/12/2019 14:20 by MD Bureau of Prisons - NYM SDNY_0001-7187 raga 1 of 3 EFTA00139024 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: Z05 Exam: Eyes General Yes: PERRLA, Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal SI and S2 No: M/R/G Abdomen Auscultation Yes: Normo-Active Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back Yes: Tenderness Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General ASSESSMENT: Constipation, unspecified, 1(5900 - Current ( N ) Yes: Normal Exam Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: Mit 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: Generated 07/1232019 14:20 by MD Bureau of Prisons - NYM SDNY_00047308 rage 2 of 3 EFTA00139025 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: 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 Handout/Topic 07/12/2019 Counseling Diagnosis Copay Required:No Telephone/Verbal Order: Completed by Beaudouin, Cosign Required: No 07/12/2019 14:20 0 Provider Outcome Verbalizes Understanding Generated 07/1232019 14:20 by MD Bureau of Prisons - NYM SDNY_0001493 of 3 EFTA00139026 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: Z05 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDO/LIPID Subjective: 66 YR O HITE MALE WITH HX OF HYPER CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MED • EIR GI SIDE EFFECTS. HX OF UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES TH Y HAS L4 - L5 SEVERE iSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREM SURGICAL HX: NONE MENTAL HEALTH HX: 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: MD 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 of 3 Generated 07/12/2019 14:20 by MD Bureau of Prisons - NYM SONY_00011499 EFTA00139027 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: Z05 Exam: Eyes General Yes: PERRLA, Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal SI and S2 No: M/R/G Abdomen Auscultation Yes: Normo-Active 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 4 2 1 % 0 Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current 1), Sleep apnea, G4730 - Current PLAN: New Medication Orders: Eta 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: Generaled 07/1212019 14:20 by MD Bureau of Prisons - NYM SDNY_0001-739:1 rage 2 of 3 EFTA00139028 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: 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 Handout/Topic 07/12/2019 Counseling Diagnosis Copay Required:No Telephone/Verbal Order: Completed by Beaudouin, Cosign Required: No 07/12/2019 14:20 co Provider Outcome Verbalizes Understanding Generated 07/12/2019 14:20 by MD Bureau of Prisons - NYM SDNY_0001:70 3 of 3 EFTA00139029 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/14/2019 17:36 Facility: NYM Amendment made to this note by MD on 07/142019 18:11. Bureau of Prisons • NYM SDNY_00017393 EFTA00139030 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: Date of Birth: Note Date: EPSTEIN, JEFFREY EDWARD 01/20/1953 07/12/2019 09:06 Sex: Provider: 1 MD Reg #: Facility: Unit: 76318-054 NYM Z05 Admin Note - Orders encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD PATIENT REQUESTED TO HAVE A COLACE RX , INSTEAD OF TEH BISACODYL FOR CONSTIPATION. New Medication Orders: 13x# Medication Docusate Sodium Capsule Indication: Constipation, unspecified Discontinued Medication Orders: I324 Medication 121757-NYM Bisacodyl E.C. 5 MG TAB Order Date 07/12/2019 09:06 Order Date 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 MD on 07/12/2019 09:10 Prescriber Order TAKE ONE 100 MG CAP Orally - Two Times a Day x 30 day(s) Prescriber Order Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10 days Generated 07/12/2919 09:10 by MD Bureau of Prisons - NYM soNy_ooPoicIld4' 1 EFTA00139031 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Facility: NYM Note Date: 07/07/2019 00:17 Provider: 1 MD Unit: E06 Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MED CL:1 NO CCC APPT. MD Discontinued Laboratory Requests: Details Frequency Due Date Priority Lab Tests-H-Hemoglobin AlC One Time 08/05/2019 00:00 Routine Lab Tests-C-CBC w/diff Lab Tests-E.-Lipid Profile Lab Tests-C-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic Additional Information: 66 y/o male, elevated BP Labs requested to be reviewed by: MD New Laboratory Requests: !Malls Frequency Due Date Priority Chronic Care Clinics-Diabetic-CBC w/diff One Time 07/25/2019 00:00 Routine Chronic Care Clinics-Diabetic-Lipid Profile Chronic Care Clinics-Diabetic-Hemoglobin A1C Lab Tests-H-HIV 1/2 Lab Tests-R-RPR Chronic Care Clinics-Diabetic-Comprehensive Metabolic Profile (CMP) New Radiology Request Orders: Details Frequency End Date Due Date Priority 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 PMHX , REFERRED FOR ROUITNE CXR. Copay Required:No TelephoneNerbal Order: No Completed by Cosign Required: No MD on 07/07/2019 00:30 Generated 07/07/2019 00:30 by MD Bureau of Prisons - NYM soNv_ooPoi9M? 1 EFTA00139032 Bureau of Prisons Health Services Health Screen Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Seizures: Denied Diabetes: Denied Cardiovascular: Denied CVA: Denied Hypertension: Denied Respiratory: Denied Sickle Cell Anemia: Denied Carcinoma/Lymphoma: Denied Allergies: Denied PPD Administration: Date/Time: 07/06/2019 21:39 Provider: PA-C Location: Right Forearm Drug Mfg: Sanofi Pasteur Lot Number: C5474BA Dosage: 0.1mL Route: ID Exp Dt: 10/2020 Comments: Tuberculosis: Hx of Previous Disease: No Blood-tinged Sputum: No Night Sweats: No Weight Loss:No Fever: No Cough:No Comments: Generated 07/06/2019 21:56 by PA-C Bureau of Prisons - NYM SDNY _00017396 'Page 1 of 6 EFTA00139033 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM 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 Paris x 3 weeks up until arrest No tattoos 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 Generated 07/06/2019 21:56 by PA-C Bureau of Prisons - NYM SONY _00017397 'Page 2 of 6 EFTA00139034 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Mental Health: Level of Consciousness: Alert 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 Fix 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: Dental Condition: Denied N/A Generated 07/06/2019 21:56 by PA-C Bureau of Prisons - NYM SDNY _00017398 'Page 3 of 6 EFTA00139035 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Observations: Draining Skin Lesions: No Signs of Lice: No Signs of Scabies: No Signs of Recent Trauma: No Recent Tattoos: No Needle Marks: No Signs of Rash: No Open Sores: No Wounds: No Body Deformities: No Tremors: No Sweating: No Comments: Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/06/2019 21:43 90 Via Machine PA-C Respirations: Date Time Rate Per Minute Provider 07/06/2019 21:43 NYM 15 PA-C Blood Pressure: Date lime Value Location Position Cuff Size Provider 07/06/2019 21:45 NYM 164/90 Right Arm Sitting Adult-regular PA-C 07/06/2019 21:43 NYM 155/83 Left Arm Sitting Adult-regular PA-C SaO2: Date Time Value(%) Air Provider 07/06/2019 21:43 NYM 95 Room Air PA-C Height: Date lime Inches Cm Provider 07/06/2019 21:43 NYM 72.0 182.9 PA-C Weight: Date Time Lbs Kg Waist Circum Provider 07/06/2019 21:43 NYM 200.0 90.7 PA-C Prosthetic Devices/Equipment: Denied Potential Items For Follow-up: Item Travel Outside US Other Infectious Disease History Comments: I have reviewed 0 pages of intake paperworks SDNY _0 9 Pa0ge 017 4 off 6 Generated 07/06/2019 21:56 by PA-C Bureau of Prisons - NYM EFTA00139036 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Health Problems Newly Identified During This Encounter: Health Problem Medication Reconciliation. The patient's known medication list including OTC items was compiled and compared to new and changed BOP orders. Reconciled Medications: Source Action Iyp.e BA Medication OTC No known OTCs Order Detail New Laboratory Requests: Details Frequency Due Date Priority Lab Tests-H-Hemoglobin A1C One Time 08/05/2019 00:00 Routine rlorty i Lab Tests-C-CBC w/diff Lab Tests-L-Lipid Profile Lab Tests-C-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic Additional Information: 66 y/o male, elevated BP Labs requested to be reviewed by: MD New Non-Medication Orders: Order Frequency Duration DeS6lls Ordered By EKG One Time 66 y/o male PA-C Order Date: 07/06/2019 Fecal Occult Blood One Time 3 different stools PA-C Order Date: 07/06/2019 Schedule: Activity Vision Screen 66 y/o male PPD Reading Follow-up BP check Date Scheduled Scheduled Provider 07/06/2019 00:00 Optometrist 07/08/2019 00:00 Nurse 07/09/2019 00:00 Mid-Level Provider Other: BP noticed to be elevated. IM denies Hx of HTN or any significant chronic medical conditions. He is currently asymptomatic and denies any bodily complaints at this time. Will recheck BP in 2-3 days. Disposition: Follow-up at Sick Call as Needed To be Evaluated by Provider Instructed inmate how to obtain medical, dental, and mental health care. Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Generated 07/06/2019 21:56 by PA-C Bureau of Prisons - NYM SONY _0001Z400 'Page 5 of 6 EFTA00139037 Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Completed by PA-C on 07/06/2019 21:56 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 07/06/2019 21:56 by PA-C Bureau of Prisons NYM SDNY _000114 -Page 6 of016 EFTA00139038 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA C Facility: NYM Cosigned with New Encounter Note by MD on 07/07/2019 00:17. Bureau of Prisons NYM SDNV_00017402 EFTA00139039 Bureau of Prisons Health Services History & Physical Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R e: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: . MLP Unit: 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 Paris x 3 weeks up until arrest No tattoos SDNY_ 00017403 Generated 07/09/2019 13:03 by-. MLP Bureau of Prisons -P NYM age I of 13 EFTA00139040 Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: H01 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 SDNY Inv 4(!.,)(1 13 Generated 07/09/2019 13:03 by-. MLP Bureau of Prisons NYM EFTA00139041 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R e: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: . MLP Unit: H01 Mental Health: Level of Consciousness: Alert 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: Dental Condition: Denied N/A Generated 07/09/2019 13:03 by . MLP Bureau of Prisons • NYM SDNY _00017405 'Pa ge 3 of 13 EFTA00139042 Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: H01 Observations: Draining Skin Lesions: No Signs of Lice: No Signs of Scabies: No Signs of Recent Trauma: No Recent Tattoos: No Needle Marks: No Signs of Rash: No Open Sores: No Wounds: No Body Deformities: No Tremors: No Sweating: No Comments: SDNY 90017406 Generated 07/09/2019 13:03 by . MLP Bureau of Prisons NYM -Page 4 of 13 EFTA00139043 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R e: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: . MLP Unit: H01 Immunizations: Hepatitis A and B (TwinRx) Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: MLP 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: MLP 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: MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Tetanus Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST SONY19404;1p3713 Generated 07;09/2019 13:03 by-. MLP Bureau of Prisons NYM EFTA00139044 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: H01 Immunization Date: Provider: MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Varicella Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Temperature: Date Time Fahrenheit Celsius Location Provider 07/09/2019 12:49 NYM 97.3 36.3 Oral . MLP Pulse: Dine Time Rate Per Minute Location Rhythm Provider 07/09/2019 12:49 82 Via Machine Regular MLP Respirations: that Time Rate Per Minute Provider 07/09/2019 12:49 NYM 16 . MLP Blood Pressure: Date Time Value Location Position Cuff Size Provider 07/09/2019 12:49 NYM 117/66 Right Arm Sitting Adult-regular MLP SaO2: Date lime Value(%) Air Provider 07/09/2019 12:49 NYM 97 Room Air MLP Height: Date lime Inches Cm Provider 07/09/2019 12:49 NYM 70.0 177.8 . MLP Generated 0710912019 13:03 by-. MLP Bureau of Prisons - NYM SDNY41m8,3 EFTA00139045 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R e: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: . MLP Unit: H01 Date Time inches Cm Provider Weight: Date Time the Kg Waist Circum. Provider 07/09/2019 12:49 NYM 194.4 88.2 . MLP Prosthetic Devices/Equipment: Denied Tobacco Usage: Denied General Social History: Foreign Travel: Born in USA: Yes Country of Birth: USA Patient Education Assessments: Date Ed Yrs Occupation Learns Best By Primary Language Barriers to Education 07/09/2019 12 Banker Speaking/Listening English None Family History - Father: Age at Death: 74 Cause of Death: Diabetes complications Significant Illnesses: Diabetes 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: 1 Significant Illnesses: Comments: Past Hospitalization: Reason Location When Acute Appendicitis Mount Sinai Hospital 1990 Complications: None Comments: Head: Normal: Yes Comments: Generated 07/09/2019 13:03 by MLP Bureau of Prisons • NYM SDNY_Fp29041;4i1f913 EFTA00139046 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R e: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: . MLP Unit: H01 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 Discs Sharp Margins: Yes Fundi Vessels Grounds Abnormal: No Eyes Comments: Vision Screen 07/09/2019 12:52 Blindness: With Corrective Distance Vision: OD: 100 OS: 70 OU: OD: OS OU: Near Vision: OD: OS: OU: OD: OS: OU: Ishlhara Color Test: Tonometry: L: R: Comments: Needs evaluation with optometrist. Ears: Right Ear: Canal patent Left Ear: Canal patent Ears Comments: Nose: Nares Patent: Yes Septum Midline:Yes Septum Intact: Yes Drainage/Discharge:No Polyps: No Nose Comments: SDNY_0001Z410 Generated 07/09/2019 13:03 by Bureau of Prisons • WIN -Page a of 13 EFTA00139047 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: ,L Uace: WHITE Encounter Date: 07/09/2019 12:35 Provider: a. MLP Reg #: 76318-054 Facility: NYM Unit: H01 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 II-XII: 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: SDNY _00017411 Generated 07/09/2019 13:03 by MLP Bureau of Prisons • NYM 'Page 9 of 13 EFTA00139048 Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/09/2019 12:35 Provider l o af e:m MLP WHITE Reg 4: 76318-054 Facility: NYM Unit: H01 Thorax: Contour Normal:Yes Increased AP Diameter: No Asymmetrical Expansion:No Lungs Clear: Yes Wheezes: No Crackles: No Rhonchi: No Rales: No Accessory Muscle Use: No Comments: Spine: Deformity: No Full ROM:Yes Tenderness:No Comments: Cardiovascular: RRR: Yes Normal S1/S2: Yes Murmurs: No Carotid Bruits:No JVD: No Arteries: Bight Left Radial: Femoral: Dorsalis Pedls: Post. Tibialis: Comments: SDNYF4V1164df213 Generated 07/09/2019 13:03 by-. MLP Bureau of Prisons NYM EFTA00139049 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: a gace: WHITE Encounter Date: 07/09/2019 12:35 Provider: MIIM MLP Reg #: 76318-054 Facility: NYM Unit: H01 Abdomen: Normal Contour:Yes Scaphoid: No Obese: No Gravid: No Hernias: No Bruits: No Masses:No Scars: No Tenderness: No Organomegaly: No Active Bowel Sounds: Yes Comments: Extremities: Nails Clubbing: No Nails Cyanosis: No Lower Extremity Edema - Right: None Lower Extremity Edema - Left: None Atrophy: No Amputations: No Other Deformities: No Varicosities:No Calf Tenderness:No Pulse Deficit: No Strength: Right 1.911 Arm: Leg: Full ROM: Bight Lett Arm: Yes Yes Leg: Yes Yes Comments: Generated 07/09/2019 13:03 by MLP SDNY4:17413 Bureau of Prisons • NYM 11 of 13 EFTA00139050 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: L Oace: WHITE Encounter Date: 07/09/2019 12:35 Provider: MLP Reg #: 76318-054 Facility: NYM Unit: H01 Reflexes: Right Left Biceps: Patellar: Brachloradialls: Achilles: Sensation: Vibratory: Yes Light Touch: Yes Pin Prick: Yes Comments: 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: Comments: No Potential Items For Follow-up: DOM 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. SDNY_000171 Generated 07/09/2019 13:03 by MLP Bureau of Prisons • NYM r' age 124o4f 13 EFTA00139051 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R e: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: . MLP Unit: H01 Cleared For Food Services: Yes Health Problems Newly Identified During This Encounter: Health Problem Constipation, unspecified - Current - New Medication Orders: Medication. Order Date Prescriber Order Bisacodyl E.C. Tablet 07/09/2019 12:35 5 mg Orally at bedtime PRN x 10 day(s) 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 Cosign Required: Yes Telephone/Verbal Order: No Completed by MLP on 07/09/2019 13:03 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. SDNY41:17415 Generated 07/09/2019 13:03 by . Bureau of Prisons • NYM 13 Of 13 EFTA00139052 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/09/2019 12:35 Provider: MLP Facility: NYM Cosigned by MD on 07/11/2019 22:41. Bureau of Prisons NYM SDNY_00017416 EFTA00139053 Bureau of Prisons Health Services Inmate Local Hospital Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD SENSITIVE BUT UNCLASSIFIED — This information is confidential and must be appropriately safeguarded. Transfer To: Transfer Date: 08/10/2019 Health Problems Health Problem Status Hyperlipidemia, unspecified Current HYPERTRIGLYCERIDEMIA Sleep apnea Current Essential (primary) hypertension Current BY HX. Constipation, unspecified Current Low back pain Current Neuralgia and neuritis, unspecified Current No Diagnosis Current Prediabetes Current Injury, unspecified Current 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 indicated. Bolded drugs required for transport. Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take one capsule (100 MG) by mouth twice daily for 30 days Docusate Sodium 100 MG Cap Exp: 01/22/2020 SIG: Take one capsule (100 MG) twice daily by mouth with plenty of water Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML Exp: 10/28/2019 SIG: shake well take 10ml by mouth twice daily AS NEEDED 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. None Pending Appointments Date Time 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 Freauency Duration Details EKG 07/06/2019 One Time 66 y/o male Fecal 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: TB Treatment: TB Follow-up Recommended: No Sickle Cell: Sickle Cell Trait/Disease: No Results: Sx free for 30 days: Yes Generated 08/10/2019 07:00 by SDNY_00017417 RN Bureau of Prisons - NYM Page 1 of 2 EFTA00139054 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD SENSITIVE BUT UNCLASSIFIED — This information is confidential and must be appropriately safeguarded. Limitations/Restrictions/Diets: Cell: lower bunk --- 10/09/2019 Cleared for Food Service: Yes Other diet restrictions: FISH ALLERGIES. --- 07/30/2020 Comments: Allergies No Known Allergies Devices / Equipment C-Pap Travel: Direct Travel: No Travel Restrictions: None UNIVERSAL PRECAUTIONS OBSERVED WHEN TRANSPORTING ANY INMATE: Transfer From Institution: NEW YORK MCC Address 1: 150 PARK ROW Address 2: City/State/Zip: NEW YORK, New York 10007 Name/Title of Person Completing Form: Phone Number: 6468366300 RN Date: 08/10/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 DOB: 01/20/1953 Sex: M Generated 08/10/2019 07:00 by SDNY_00017418 RN Bureau of Prisons - NYM Page 2 of 2 EFTA00139055 Bureau of Prisons Health Services Vitals All Begin Date: 07/06/2019 Reg #: 76318-054 End Date: 05/11/2020 Inmate Name: EPSTEIN, JEFFREY EDWARD Temperature: Date Time Fahrenheit Celsius Location 07/24/2019 13:12 NYM 97.8 36.6 Oral Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 NYM 97.5 36.4 Oral Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM 97.3 36.3 Oral Orig Entered: 07/09/2019 12:51 EST Pulse: Date Time 07/30/2019 13:02 Bate Per Minute Location 94 Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:40 Orig Entered: 07/30/2019 09:30 Orig Entered: 07/28/2019 20:28 Orig Entered: 07/28/2019 06:57 Orig Entered: 07/24/2019 13:12 Orig Entered: 07/23/2019 06:30 Orig Entered: 07/09/2019 12:49 Orig Entered: 07/06/2019 21:43 Orig Entered: Respirations: Date Time 07/30/2019 09:30 Orig Entered: 07/28/2019 20:28 Orig Entered: 07/28/2019 06:57 Orig Entered: 07/23/2019 06:30 Orig Entered: 07/09/2019 12:49 07/30/2019 13:04 07/30/2019 12:59 07/28/2019 20:29 07/28/2019 06:58 07/24/2019 13:14 07/23/2019 08:33 07/09/2019 12:51 07/06/2019 21:48 MLP MLP MLP 88 Via Machine EST 87 Via Machine EST 81 EST 82 EST 83 EST 92 EST 82 EST 90 EST Provider . MLP . MLP . MLP EDO= Provider MD MD MD RN RN Via Machine Regular MLP Via Machine Regular MLP Via Machine Regular MLP Via Machine PA-C Rate Per Minute Provider NYM 12 07/30/2019 12:59 EST NYM 14 07/28/2019 20:29 EST NYM 07/28/2019 06:58 EST NYM 07/23/2019 08:33 EST NYM MD MD RN RN 14 RN TM,MLP MLP 16 . MLP RN MD MD MD RN RN MLP MLP MLP PA-C Generated 05/11/2020 09:57 by Allen, Tamara OGC Bureau of Prisons DAN SDNY 00017419 — Page 1 el 3 EFTA00139056 Begin Date: 07/06/2019 Reg #: 76318.054 End Date: 05/11/2020 Inmate Name: EPSTEIN, JEFFREY EDWARD Date Time Rate Per Minute Provider Orig Entered: 07/09/2019 12:51 EST . MLP 07/06/2019 21:43 NYM 15 PA-C Orig Entered: 07/06/2019 21:48 EST PA-C Blood Pressure: Date Time Value 07/30/2019 13:02 NYM 114/84 Location Left Arm Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:40 NYM 125/60 Right Arm Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:30 NYM 108/86 Left Arm Orig Entered: 07/30/2019 12:59 EST 07/28/2019 20:28 NYM 157/91 Orig Entered: 07/28/2019 20:29 EST 07/28/2019 06:57 NYM 138/80 Orig Entered: 07/28/2019 06:58 EST 07/24/2019 13:12 NYM 132/89 Right Arm Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 NYM 140/85 Right Arm Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM 117/66 Right Arm Orig Entered: 07/09/2019 12:51 EST 07/06/2019 21:45 NYM 164/90 Right Arm Orig Entered: 07/06/2019 21:48 EST 07/06/2019 21:43 NYM 155/83 Left Arm Orig Entered: 07/06/2019 21:48 EST Blood Glucose: Date 08/04/2019 Orig 08/02/2019 Orig 08/01/2019 Orig 07/31/2019 Orig Position Standing Standing Sitting Sitting MLP Sitting MLP Sitting MLP Sitting PA-C Sitting PA-C Time Value (mg/d11 Ivo 08:30 156 Non-Fasting Entered: 08/04/2019 09:08 EST 06:30 97 Non-Fasting Entered: 08/02/2019 08:16 EST 06:30 103 Non-Fasting Entered: 08/01/2019 09:00 EST 06:15 108 Non-Fasting Entered: 07/31/2019 08:36 EST SaO2: Date lime Value(%) Air 07/30/2019 09:30 NYM 98 Room Air Orig Entered: 07/30/2019 12:59 EST 07/28/2019 20:28 NYM 98 Orig Entered: 07/28/2019 20:29 EST 07/28/2019 06:57 NYM 98 Generated 05/11/2020 09:57 by Allen. Tamara OGC MLP MLP MLP Cuff Size provider MD MD MD RN RN Adult-regular Adult-regular Adult-regular Adult-regular Adult-regular MD MD MD RN RN MLP MLP MLP PA-C PA-C Regular Insulin Provider RN Provider MD RN Bureau of Prisons DAN MD RN RN RN . MLP . MLP . MLP SDNY 00017420 - Page 2 of 3 EFTA00139057 Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date Time Value(%) Air Provider Orig Entered: 07/28/2019 06:58 EST RN 07/24/2019 13:12 NYM 96 Room Air . MLP Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 NYM 96 Room Air Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM 97 Room Air Orig Entered: 07/09/2019 12:51 EST 07/06/2019 21:43 NYM 95 Room Air Orig Entered: 07/06/2019 21:48 EST MLP MLP MLP PA-C Height: Date Time Jnches Cm Provider 07/09/2019 12:49 NYM 70.0 177.8 MLP Orig Entered: 07/09/2019 12:51 EST MLP 07/06/2019 21:43 NYM 72.0 182.9 PA-C Orig Entered: 07/06/2019 21:48 EST PA-C Weight: Date Time J,kg Kg. Waist Circum Provider 07/30/2019 09:30 NYM 194.2 88.1 MLP MLP PA-C Orig Entered: 07/30/2019 12:59 EST MD 07/09/2019 12:49 NYM 194.4 88.2 . MLP Orig Entered: 07/09/2019 12:51 EST 07/06/2019 21:43 NYM 200.0 90.7 Orig Entered: 07/06/2019 21:48 EST MLP PA-C PA-C MD Generated 05/11/2020 09:57 by Allen, Tamara OGC Bureau of Prisons - DAN SDNY 00017421 - Page 3 of 3 EFTA00139058 Bureau of Prisons Health Services PPDs Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Admin: Location 07/06/2019 21:39 Right Forearm Orig Entered: 07/06/2019 21:43 EST Total: 1 Provider PA-C PA-C Reading, Induration : Provider 07/09/2019 12:47 0 mm MLP Orig Entered: 07:09'2019 12:47 EST MLP Generated 05,11,2020 09:57 by Allen. Tamara OGC SONY 00017422 Bureau ol Prisons - DAN Page 1 ol EFTA00139059 76318-054 EPSTEIN. JEFFREY Medication Orders Medication Administration Record JULY 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 Ord. Date 07.3019 1421 Exp. Date 07,3109 10.01 Inject regular insulin subcutaneously per sliding scale: twice daily —pill line"' for 7 days NYM 122148- NYM Insulin Reg (10 ML) 100 UNITSML MD PAN Ord. Date 07.31119 1000 Exp. Date 0807019 09:59 MD Inject regular insulin subcutaneously per sliding scale: each morning for 7 days "'pill line"' NYM 122160 NYM Insulin Reg (10 ML) 100 UNITSML In! PAN Providers: YJ Documentation Codes: ORD - Order I NI -- Dose Not Indicated Registration 4. 76318-054 Pt. Name: EPSTEIN. JEFFREY DOB: 01.20:53 Report information is current as of the date and time of printing: 05. 11.2020 (43151,Em 0,7423 EFTA00139060 76318.054 EPSTEIN. JEFFREY Medication Orders 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 Ord. Date 0'731/9 10 00 Exp. Dale 0807/19 09:59 MD Inject regular insulin subcutaneously per sliding scale: each morning for 7 days "'pill line— NYM 122160- NYM Insulin Reg (10 ML) 100 UNITSML Iry VAN Providers: YJ Documentation Codes: ORD = Order I NI -- Dose Not Indicated Registration #. 76318-054 Pt. Name: EPSTEIN. JEFFREY DOB: 01.20:53 Report information is current as of the date and time of printing: 0511.2020 L._ (NT, E m0,7424 EFTA00139061 Bureau of Prisons Health Services Devices and Equipment Start Date: 07/06/2019 Stop Date: 05/11/2020 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Device/Equipment Start Date Stop Date Date Returned Obtained From Comments C-Pap 07/30/2019 14:05 EST MD 07/30/2019 Personal PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Total: 1 Generated 05/11/2020 09:57 by Allen, Tamara OGC Bureau of Prisons - DAN SDNY_0001744099 1 of 1 EFTA00139062 Bureau of Prisons Health Services Pain Management Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Date Intervention 07/12/2019 13:25 MEDROL DOSE PACK Orig Entered: 07/12/2019 13:28 EST MD Pain Quality Location Pie Post Provider Shooting Back-Middle 5 MD Generated 05/11/2020 09:57 by Allen, Tamara OGC Bureau of Prisons • DAN SDNY 00017426 - Page 1 of 1 EFTA00139063 Bureau of Prisons Health Services Modified Diet Request Types of Diets: Clear Liquid Exp Date: Low Fat Exp Date: Mechanical Soft Exp Date: Low Cholesterol Exp Date: Low Triglyceride Exp Date: Renal Exp Date: _ Full Liquid Exp Date: Sodium Controlled Exp Date: _ Snack Exp Date: Diabetic Exp Date: Calorie Controlled Exp Date: X Other: FISH ALLERGIES. Exp Date: 07/30/2020 Comments: MD Health Service Staff EPSTEIN, JEFFREY EDWARD Inmate Name 76318-054 07/30/2019 Reg# Date Generated 07/30/2019 14:57 by SDNY_00017427 MD Bureau of Prisons - NYM Page 1 of 1 EFTA00139064 Bureau of Prisons Health Services Allergies Reg li: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Mem No Known Allergies Orig Entered: Total: 1 07/06/2019 21:40 EST Date Noted Reaction 07/06/2019 PA-C Generated 05/11/2020 09:57 by Allen. Tamara OGC Bureau of Prisons - DAN SDNY_00017428 Page 1 of 1 EFTA00139065 Bureau of Prisons Health Services Patient Education Assessments & Topics Reg 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Assessments Assessment Learns Best By Primary Language Years of Education Barriers To Education 07/09/2019 Speaking/Listening English 12 None Orig Entered: 07/09/2019 12:52 EST Total: 1 Topics Date initiated Format flandouVTopic 07/30/2019 Counseling Access to Care Orig Entered: 07/30/2019 13:33 EST 07/30/2019 Counseling Plan of Care Orig Entered: 07/30/2019 13:34 EST 07/28/2019 Counseling Plan of Care Orig Entered: 07/28/2019 07:22 EST 07/28/2019 Counseling Plan of Care Orig Entered: 07/28/2019 20:30 EST 07/24/2019 Counseling Access to Care Orig Entered: 07/24/2019 13:23 EST 07/24/2019 Counseling Preventive Health Orig Entered: 07/24/2019 13:23 EST 07/23/2019 Counseling Access to Care Orig Entered: 07/23/2019 09:04 EST 07/23/2019 Counseling Plan of Care Orig Entered: 07/23/2019 09:04 EST 07/14/2019 Counseling Diagnosis Orig Entered: 07/14/2019 18:11 EST 07/12/2019 Counseling Diagnosis Outcome Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Provider Provider Generated 05/11/2020 09:57 by Allen. Tamara OGC Bureau of Prisons • DAN S0NY_00017429 Page 1 of 2 EFTA00139066 Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Topics Date Initiated Format flandouUTopic Orig Entered: 07;12/2019 13:33 EST Total: 10 Outcome Provider Generated 05,1112020 09:57 by Allen, Tamara OGC SDNY00017430 Bureau of Prisons - DAN Page 2 of 2 EFTA00139067 Bureau of Prisons Health Services Blood Glucose Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD (Reference Range: Random or Fasting 70 - 100, 2 hour post-prandial 70 - 140) Date lime Value Type 08/04/2019 08:30 NYM 156 Non-Fasting Orig Entered: 08/04/2019 09:08 EST RN 08/02/2019 06:30 NYM 97 Non-Fasting Orig Entered: 08/02/2019 08:16 EST MLP 08/01/2019 06:30 NYM 103 Non-Fasting Orig Entered: 08/01/2019 09:00 EST MLP 07/31/2019 06:15 NYM 108 Non-Fasting Orig Entered: 07/31/2019 08:36 EST MLP Total: 4 Comments Generated 05/11/2020 09:57 by Allen, Tamara OGC Bureau of Prisons • DAN S0NY_00017431 Page 1 of 1 EFTA00139068 Bureau of Prisons Health Services Health Problems Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Description Ana Code Type Code Diag. Date Status Status Date Current Hyperlipidemia, unspecified 07/12/2019 13:48 EST MD ICD-10 E785 07/12/2019 Current HYPERTRIGLYCERIDEMIA Sleep apnea 07/12/2019 13:56 EST MD ICD-10 G4730 07/12/2019 Current Essential (primary) hypertension 07/30/2019 13:13 EST MD ICD-10 110 07/30/2019 Current BY HX. Constipation, unspecified 07/09/2019 12:58 EST MLP ICD-10 K5900 07/09/2019 Current Low back pain 07/12/2019 13:30 EST MD ICD-10 M545 07/12/2019 Current Neuralgia and neuritis, unspecified 07/12/2019 13:30 EST MD ICD-10 M792 07/12/2019 Current No Diagnosis 07/09/2019 10:28 EST PhD/Chief I DSM-IV No Dx 07/09/2019 Current Psychologist Prediabetes 07/30/2019 13:26 EST MD ICD-10 R7303 07/30/2019 Current Injury, unspecified 07/23/2019 09:04 EST MLP ICD-10 T1490 07/23/2019 Current R/O self inflicted injuries. Body mass index (BMI) 27.0-27.9, adult 07/30/2019 13:14 EST MD ICD-10 Z6827 07/30/2019 Current Total: 10 Generated 05/11/2020 09:57 by Allen, Tamara OGC Bureau of Prisons • DAN S0NY_00017432 Page 1 of 1 EFTA00139069 Bureau of Prisons Health Services Vision Screens Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Vision Screen on 07/09/2019 12:52 Blindness: Distance Vision: OD: 20/100 OS: 20/70 OU: Near Vision: OD: OS: OU: With Corrective Distance Vision: OD: OS: OU: Near Vision: OD: OS: OU: Present Glasses - Distance Refraction - Distance Sphere Cylinder Axis Add Sphere Cylinder Axis Add R: R: L: L: Color Test: Tonometry: R: L: Comments: Needs evaluation with optometrist. Orig Entered: 07/09/2019 12:54 EST . MLP Generated 05/11/2020 09:57 by Allen, Tamara OGC SDNY 00017433 Bureau of Prisons - DAN — Page 1 of 1 EFTA00139070 Bureau of Prisons Health Services Immunizations Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Immunization Jmmunization Date Administered Location Dosage Drug Mfg latit gxp Date Hepatitis A and B (TwinRx) History Unknown Orig Entered: 07/09/2019 12:51 EST MLP Measles/Mumps/Rubella Series History Unknown Orig Entered: 07/09/2019 12:51 EST MLP Smallpox Series History Unknown Orig Entered: 07/09/2019 12:51 EST Tetanus -. MLP History Unknown Orig Entered: 07/09/2019 12:51 EST MLP Varicella Series History Unknown Orig Entered: 07/09/2019 12:51 EST Total: 5 MLP Generated 05/11/2020 09:57 by Allen, Tamara OGC Bureau of Prisons • DAN S0NY_00017434 Page 1 of EFTA00139071 Bunau of Prisons Hear! Services Medical Duty Status Reg #: 76318-054 in. late Name: EPSTEIN. JEFFREY EDWARD Housing Status confined to the living quarters except _meals pill line _ _treatments Exp. Date: _ on complete bed rest: _bathroom privileges only Exp. Date: X cell: cell on first floor single cell X lower bunk airborne infection isolation Exp. Date: 10:09/2019 other: Exp. Date: Physical limitation/Restriction all sports Exp. Date: weightlifting: _upper body _lower body Exp. Date: cardiovascular exercise: _running _jogging _walking _softball Exp. Date: _football _basketball _handball _stationary equipment other: Exp. Date: May have the following equipment in his / her possession: Equipment Start Date C-Pap 07/30,2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Work Restriction / Limitation: Cleared for Food Service: Yes X No Restrictions Comments: N/A Beaudouin, Robert MD Health Services Staff Date End Date Return Date 07/30/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Quarters: null ALL EXPIRATION DATES A RE AT 24:00 Generated 05/11/2020 09:57 by Allen. Tamara OGC DA .) - DAN SDNY 00017435 Page 1 oft EFTA00139072 Bunau of Prisons Hear! Services Medical Duty Status Reg #: 76318-054 in. late Name: EPSTEIN. JEFFREY EDWARD Housing Status confined to the living quarters except _meals pill line _ _treatments Exp. Date: _ on complete bed rest: _bathroom privileges only Exp. Date: X cell: cell on first floor single cell X lower bunk airborne infection isolation Exp. Date: 10:09/2019 other: Exp. Date: Physical limitation/Restriction all sports Exp. Date: weightlifting: _upper body _lower body Exp. Date: cardiovascular exercise: _running _jogging _walking _softball Exp. Date: _football basketball handball stationary equipment other: May have the following equipment in his / her possessio Work Restriction / Limitation: Cleared for Food Service: Yes X No Restrictions Comments: N/A MLP Exp. Date: 07/09/2019 Health Services Staff Date Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Quarters: null ALL EXPIRATION DATES ARE AT al:00 ,t‘ V 4I Y ir i9 t e a l .< se b t • t Got C 4 1Ok e 0 euret - DAN Generated 05/11/2020 09:57 by Allen. Tamara OGC SONY 00017436 Page 1 (21 EFTA00139073 Bureau of Prisons Health Services Medication Summary Historical Complex: NYM--NEW YORK MCC Inmate: EPSTEIN, JEFFREY EDWARD Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318-054 Quarter: ???-???? Medications listed reflect prescribed medications from the begin date to end date on this report. Allergies: Denied Active Prescriptions Bisacodyl E.C. 5 MG TAB Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10 days Rx#: 121757-NYM Doctor: MLP Start: 07/09/19 Exp: 07/19/19 D/C: 07/12/19 Pharmacy Dispensings: 10 TAB in 307 days Docusate Sodium 100 MG Cap Take one capsule (100 MG) by mouth twice daily for 30 days Rx#: 121823-NYM Doctor: MD Start: 07/12/19 Exp: 08/11/19 D/C: 08/10/19 Pharmacy Dispensings: 60 CAP in 304 days Docusate Sodium 100 MG Cap Take one capsule (100 MG) twice daily by mouth with plenty of water Rx#: 122084-NYM Doctor: MD Start: 07/26/19 Exp: 01/22/20 D/C: 08/10/19 Pharmacy Dlspensings: 30 CAP in 290 days Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML shake well take 2 tablespoonful twice daily by mouth Rx#: 121835-NYM Doctor: MD Start: 07/12/19 Exp: 07/14/19 Pharmacy Dispensings: 473 ML in 304 days Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML shake well take 10ml by mouth twice daily AS NEEDED Rx#: 122150-NYM Doctor: MD Start: 07/30/19 Exp: 10/28/19 D/C: 08/10/19 Pharmacy Dispensings: 473 ML in 286 days methylPREDNISolone 4 MG Tab [ 21 count Pack) Take the tablet by mouth as directed Rx#: 121836-NYM Doctor: MD Start: 07/12/19 Exp: 07/18/19 Pharmacy Dispensings: 21 tab in 304 days methylPREDNISolone 4 MG Tab [ 21 count Pack) Take the tablet by mouth as directed Rx#: 122149-NYM Doctor: MD Start: 07/30/19 Exp: 08/05/19 Pharmacy Dispensings: 21 tab in 286 days Generated 05/11/2020 09:57 by Allen, Tamara OGC SDNV 00017437 Bureau of Prisons _ sons - DAN Page 1 of 2 EFTA00139074 Complex: NYM--NEW YORK MCC Inmate: EPSTEIN, JEFFREY EDWARD Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318-054 Quarter: ???-???? Active Prescriptions Omega 3 (Vascepa) 1 GM Capsule Take two capsules (2 GM) twice daily by mouth with food Rx#: 121885-NYM Doctor: MD Start: 07/17/19 Exp: 01/13/20 D/C: 08/10/19 Pharmacy Dispensings: 180 Cap in 299 days Insulin Reg (10 ML) 100 UNITS/ML Inj Inject regular insulin subcutaneously per sliding scale: twice daily "'pill line— for 7 days "'pill line— Rx#: 122148-NYM Doctor: MD Start: 07/30/19 Exp: 08/06/19 D/C: 07/31/19 Pharmacy Dispensings: 0 ML in 286 days Insulin Reg (10 ML) 100 UNITS/ML Inj Inject regular insulin subcutaneously per sliding scale: each morning for 7 days "'pill line"' "'pill line"' Rx#: 122160-NYM Doctor: Start: 07/31/19 Exp: 08/07/19 MD Pharmacy Dispensings: 0 ML in 285 days Generated 05/11/2020 09:57 by Allen, Tamara OGC SDNY_00017438 Bureau of Prisons • DAN Page 2 of 2 EFTA00139075 Bureau of Prisons Health Services Dental Health History Screen Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/26/2019 07:54 Provider: DDS Unit: H01 ASSESSMENTS: Health Problems as of Dental Health History Encounter date: 07/26/2019 07:54 Health Problems Health Problem Status Hyperlipidemia, unspecified Current HYPERTRIGLYCERIDEMIA Sleep apnea Current Constipation, unspecified Current Low back pain Current Neuralgia and neuritis. unspecified Current No Diagnosis Current Injury, unspecified Current R/O self inflicted injuries. 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 Cell Anemia: Denied Carcinoma/Lymphoma: Denied HIV History: When Tested: 2019 Test Result: Negative When Diagnosed AIDS: Last CD4: Comments: Hepatitis: Denied SDNY_K09137,713.3? 3 Generated 07;26,2019 07:59 by DDS Bureau of Prisons - NYM EFTA00139076 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/26/2019 07:54 Provider: DDS Unit: H01 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 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 Sensitive teeth: No Bleeding gums: Yes 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 Decayed teeth: No Loose teeth: No Wear dentures: No None: No Comments: Generated 07/26:2019 07:59 by ODS Bureau of Prisons - NYM SDNY40a0glett o? 3 EFTA00139077 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/26/2019 07:54 Provider: DDS Unit: H01 Cardiac Condition Requiring Prophylaxis: No Prosthetic joint(s): No Radiation history of head or neck: No Excessive bleeding: No Bisphosphonates: No Comments: Medications as of Dental Health History Encounter date: 07/26/2019 07:54 Medications: 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. Instructed inmate how to obtain medical, dental, and mental health care. Copay Required:No Cosign Required: No Telephone/Verbal Order: No Completed by DDS on 07/26/2019 07:59 SDNY_R0gle7314.31 3 Generated 07/26/2019 07:59 by DDS Bureau of Prisons - NYM EFTA00139078 Bureau of Prisons Health Services Dental A&O Exam Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/26/2019 07:47 Provider: Reg #: 76318-054 Facility: NYM DDS Unit: H01 Reviewed Health Status: Yes Occlusion: Class I Oral Hygiene: Fair CPITN: 3 2 3 3 2 3 Hard and soft tissue examination performed and documented on BP618 form: Yes Head & Neck/Soft Tissue within normal limits? No Comments: moderate to advanced upper posterior gingival recession 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 given: Yes Dental A&O Screening Exam findings entered on EPSTEIN, JEFFREY EDWARD by DDS on 07/26/2019 07:47. SDNY_ROg1e714401 Generated 07/26/2019 08:00 by DDS Bureau of Prisons - NYM EFTA00139079 Bureau of Prisons Health Services Dental Soap/Admin Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/18/2019 13:48 Provider: DeBruce, Juanita Dental Asst Unit: Z05 Screening encounter at Dental Clinic. Reason Not Done: Unavailable Comments: Patient has had several call outs for his Dental A & O screening but has not been escorted to the dental clinic. Cosign Required: No Completed by DeBruce, Juanita Dental Asst on 07/19/2019 13:49. Generated 07/19/2019 13:49 by DeBruce. Juanita Dental SDNY_00017443 Bureau of Prisons • NYM Page 1 of 1 EFTA00139080 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 08/08/2019 10:02 Provider: PhD/Chief Reg #: 76318-054 Unit Team: 5 Focus of Session Inmate Epstein was seen today for a follow-up session in SHU. Subjective/Objective Presentation Inmate Epstein stated he is feeling okay and has been eating his meals. He reported his sleep as "fair" and would like to go the general population. He denied any mental health symptoms at this time and denied any feelings of depression and/or anxiety. Inmate Epstein denied any suicidal ideation, intention, or plan. He currently has a cellmate and appears to interact with him. Inmate Epstein continues to spend his days and evening with his attorney's in the attorney conference room. He told this writer he received his PAC number to make phone calls. Inmate Epstein indicated he has only had a couple of phone calls over the speaker phone and wondered "if that counted" as his monthly phone contact. He also reported he his missing some books he was reading in the suicide watch area prior to returning to the SHU. Other than complaints about the prison and concerns regarding his housing, he had no mental health concerns today. He did not appear to be in any distress and the SHU Staff have not reported any unusual behaviors on his part. fntervention(s) Inmate EPSTEIN was provided with brief supportive interventions and psychoeducation regarding additional coping strategies. Inmate EPSTEIN was receptive to these interventions. Progress/Plan Inmate EPSTEIN was educated about both routine and emergency procedures for contacting Psychology staff. He was reminded of the self-help books and audiotapes available through the Psychology department. There appears to be no need for follow up at this time. He will be seen in weekly rounds and monthly for SHU reviews. Completed by PhD/Chief Psychologist on 08/08/2019 10:09 Generated 08/08/2019 10:09 by PhD/Chiel Bureau of Prisons - NYM SDNY 00017444 Page 1 of 1 EFTA00139081 Bureau of Prisons Psychology Services Suicide Risk Assessment "SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facilit : NYM Date: 08/01/2019 13:29 Provider: PsyD Reg #: 76318-054 Unit Team: 5 Type of Housing: SHU- Administrative Segregation Cell Accommodation: Double-Cell FINDINGS This assessment and the resulting recommendations are based on the following sources of information: Clinical Interview, Medical Record, Psychology Data System, Sentry Reason for Referral R & D staff reported to this writer this morning at about 8:30 AM on 8/01/19 that yesterday when Mr. Epstein was brought back from court the US Marshals asked him to sign a form that noted Mr. Epstein has "suicidal tendencies." Mr. Epstein was seen for a Suicide Risk Assessment at about 1:00 PM on 8/01/19 in Attorney Conference. This note is being entered at about 4:20 PM on 8/01/19. Mental Health History According to a Suicide Risk Assessment dated 7/09/19 by Dr. "Inmate Epstein denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time." Self-Harm History According to a Suicide Risk Assessment dated 7/09/19 by Dr. "Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in the past." According to this writer's Suicide Risk Assessment dated 7/23/19, "It is unclear at this time if he had placed the string around his neck or if someone else did." Current Problem R & D staff reported to this writer this morning at about 8:30 AM on 8/01/19 that yesterday when Mr. Epstein was brought back from court the US Marshals asked him to sign a form that noted Mr. Epstein has "suicidal tendencies." This is likely due to the incident on 7/23/19, but as a precaution another Suicide Risk Assessment was conducted. Mr. Epstein seemed surprised that there was a form noting suicidal tendencies. He denied stating he was suicidal. He said he saw the DHO