Text extracted via OCR from the original document. May contain errors from the scanning process.
Inmate Name:
Reg #:
76318-054
Dale of Birth:
Sex:
M
Race: WHITE
Facility:
NYM
Encounter Date: 07/09/2019 12:35
Provider:
MLP
Unit:
1101
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 St/S2: Yes
Murmurs: No
Carotid Bruits:No
JVD: No
Arteries:
Bight
Left
Radial:
Femoral:
Dorsalis Pedis:
Post. Tibialis:
Comments:
Generated 07/09/2019 13:03 by =E.
MLP
Bureau of Prisons - NVM
Page 10 of 13
CONFIDENTIAL
SDNY_00009437
EFTA00139342
Inmate Name:
Date of Birth:
Sex:
M
Race: WHITE
Encounter Date: 07/09/2019 12:35
Provider:
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:
Sight
Lett
Arm:
Leg:
Full ROM:
flight
Lett
Arm:
Yes
Yes
Leg:
Yes
Yes
Comments:
Generated 07/0912019 13.03 by =M.
MLP
Bureau of Prisons - NYM
Page 11 of 13
CONFIDENTIAL
SDNY_00009438
EFTA00139343
Inmate Name:
Date of Birth:
Sex:
M
Race: WHITE
Encounter Date: 07/09/2019 12:35
Provider.
MLP
Reg #:
76318-054
Facility:
NYM
Unit:
H01
Reflexes:
Right
Left
Biceps:
Patellar:
Brachioradialis:
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: No
Comments:
Potential Items For Follow-up:
Travel Outside US
Other Infectious Disease History
Rectum Not Done
Male Genitalia Not Done
PPD Administration Not Performed
Comments:
Patient has a history of constipation.
Generated 07/09/2019 13:03 by S
MLR
Bureau of Prisons-NYM
Page 12d 13
CONFIDENTIAL
SDNY_00009439
EFTA00139344
Inmate Name:
Date of Birth:
Sex:
M
Race: WHITE
Encounter Date: 07/09/2019 12:35
Provider:
MLP
Reg #:
76318-054
Facility:
NYM
Unit:
H01
Cleared For Food Services: Yes
Health Problems Newly Identified During This Encounter:
Health Problem
Constipation, unspecified - Current -
New Medication Orders:
Rxit
Medication
Order Date
Prescriber Order
Bisacodyl E.C. Tablet
07/09/201912:35
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
TelephoneNerbal 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.
Generated 07/09/2019 13:03 by
MLP
Bureau of Prisons - NYM
Page 13 of 13
CONFIDENTIAL
SDNY_00009440
EFTA00139345
Bureau of Prisons
Health Services
Cosign/Review
Inmate Name:
Reg #:
76318-054
Date of Birth:
Sex:
M
Race:
WHITE
Encounter Date: 07/09/2019 12:35
Provider:
MLP
Facility:
NYM
Cosigned by
MD on 07/11/2019 22:41.
Bunssu of FMsons NYM
CONFIDENTIAL
SONY 00009441
EFTA00139346
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
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
Data
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 Data
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 08110/2019 07:00 by
CONFIDENTIAL
RN
Bureau of Prisons - NYM
Page 1 of 2
SDNY_00009442
EFTA00139347
Reg #: 76318-054
Inmate Name: EPSTEIN, JEFFREY EDWARD
SENSITIVE BUT UNCLASSIFIED — This information is confidential and must be appropriately safeguarded.
Limitations/Restrictions/Diets:
Cell: tower 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
Transfer From Institution: NEW YORK MCC
Phone Number: 6468366300
Address 1: 150 PARK ROW
Address 2:
City/State/Zip: NEW YORK, New York 10007
Name/Title of Person Completing Form:
RN
Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #:
76318-054
DOB:
Sex:
M
Generated 08110/2019 07:00 by
CONFIDENTIAL
RN
Bureau of Rims - NYM
Page 2ot 2
SONY 00009443
EFTA00139348
Bureau of Prisons
Health Services
Vitals All
Begin Date: 07/07/2019
End Date:
08/10/2019
Reg #:
76318-054
Inmate Name: EPSTEIN, JEFFREY EDWARD
Temperature:
Rat
Time
Fahrenheit Celsius Location
Provider
07/24/2019
13:12 NYM
97.8
36.6 Oral
a
MLP
Orig Entered: 07/24/2019 13:14 EST a.
MLP
07/23/2019
06:30 NYM
97.5
36.4 Oral
MLP
Orig Entered: 07/23/2019 08:33 EST a.
MLP
07/09/2019
12:49 NYM
97.3
36.3 Oral
a
MLP
Orig Entered: 07/09/2019 12:51 EST
MLP
Pulse:
Dan
Time
Rate Per Minute
07/30/2019 13:02
94
Orig Entered: 07/30/2019 13:04 EST
07/30/2019 09:40
88
Orig Entered: 07/30/2019 13:04 EST
07/30/2019 09:30
87
Orig Entered: 07/30/2019 12:59 EST
07/28/2019 20:28
81
Orig Entered: 07/28/2019 20:29 EST
07/28/2019 06:57
82
Orig Entered: 07/28/2019 06:58 EST
07/24/2019 13:12
83
Orig Entered: 07/24/2019 13:14 EST
07/23/2019 06:30
92
Orig Entered: 07/23/2019 08:33 EST
07/09/2019 12:49
82
Orig Entered: 07/09/2019 12:51 EST
Location
Rhythm
Provider
MD
MD
Via Machine
MD
MD
Via Machine
MD
MD
RN
RN
Via Machine
Regular
. MLP
Via Machine
Regular
MLP
Via Machine
Regular
MLP
Respirations:
Dan
Time
Rate Per Minute provider
07/30/2019
09:30 NYM
12
MD
Orig Entered: 07/30/2019 12:59 EST
07/28/2019
20:28 NYM
14
MD
RN
Orig Entered: 07/28/2019 20:29 EST
RN
07/28/2019
06:57 NYM
14
Orig Entered: 07/28/2019 06:58 EST
RN
07/23/2019
06:30 NYM
TIM
I MLP
Orig Entered: 07/23/2019 08:33 EST
. MLP
07/09/2019
12:49 NYM
16
MLP
Orig Entered: 07/09/2019 12:51 EST
MLP
Generated 0811 oriole 11:02 by
RN
MLP
MLP
MLP
RN
RN
Bureau of Prisons NYM
Page 1 of 3
CONFIDENTIAL
SDNY_00009444
EFTA00139349
Begin Date: 07/07/2019
End Date:
08/10/2019
Reg #:
76318.054
Inmate Name: EPSTEIN, JEFFREY EDWARD
Blood Pressure:
age
Time
Value
07/30/2019 13:02 NYM 114/84
Location
Position
Cuff Size
Provider
Left Arm
Standing
Orig Entered: 07/30/2019 13:04 EST
07/30/2019 09:40 NYM 125/60
Right Arm
Standing
Orig Entered: 07/30/2019 13:04 EST
07/30/2019 09:30 NYM 108/86
Left Arm
Sitting
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
Sitting
Orig Entered: 07/24/2019 13:14 EST
07/23/2019 06:30 NYM 140/85
Right Arm
Sitting
Orig Entered: 07/23/2019 08:33 EST
07/09/2019 12:49 NYM 117/66
Right Arm
Sitting
Orig Entered: 07/09/2019 12:51 EST
MLP
MLP
MLP
Blood Glucose:
Date
iT me
Yalu_e_ftrigLdll
IYRe
08/04/2019
08:30
156
Non-Fasting
Orig Entered: 08/04/2019 09:08 EST
08/02/2019
06:30
97
Non-Fasting
Orig Entered: 08/02/2019 08:16 EST a
MLP
08/01/2019
06:30
103
Non-Fasting
Orig Entered: 08/01/2019 09:00 EST a.
MLP
07/31/2019
06:15
108
Non-Fasting
Orig Entered: 07/31/2019 08:36 EST
MLP
SaO2:
Date
07/30/2019
Orig
07/28/2019
Orig
07/28/2019
Orig
07/24/2019
Orig
07/23/2019
Orig
07/09/2019
Orig
Height:
Time
Value(%) Air
09:30 NYM
98 Room Air
Entered: 07/30/2019 12:59 EST
20:28 NYM
98
Entered: 07/28/2019 20:29 EST
06:57 NYM
98
Entered: 07/28/2019 06:58 EST
13:12 NYM
96 Room Air
Entered: 07/24/2019 13:14 EST
06:30 NYM
96 Room Air
Entered: 07/23/2019 08:33 EST
12:49 NYM
97 Room Air
Entered: 07/09/2019 12:51 EST
Generated 08/1012019 11.02 by
MD
MD
MD
RN
RN
Adult-regular
MLP
Adult-regular a
MLP
Adult-regular
MLP
Begukr Insulin
Provider
RN
Provider
MD
RN
RN
MLP
MLP
MLP
MLP
MLP
Bureau of Prisons NYM
MLP
MD
RN
RN
MD
MD
MD
RN
RN
RN
MLP
MLP
MLP
Page 2 of 3
CONFIDENTIAL
SDNY_00009445
EFTA00139350
Begin Date: 07/07/2019
End Date:
08/10/2019
Reg #:
76318-054
Inmate Name: EPSTEIN, JEFFREY EDWARD
Date
Time
Inches
cm
Provider
07/09/2019 12:49 NYM
70.0
177.8
la.
MLP
Orig Entered: 07/09/2019 12:51 EST a.
MLP
Weight:
Q~g
Time
Mu
Kg Waist Circum, provider
07/30/2019
09:30 NYM
194.2
88.1
MD
Orig Entered: 07/30/2019 12:59 EST
07/09/2019
12:49 NYM
194.4
88.2
MD
. MLP
Orig Entered: 07/09/2019 12:51 EST
MLP
Generated 08110/2019 11:02 by
Bureau of Prisons • NYM
Page 3 of 3
CONFIDENTIAL
SDNY_00009446
EFTA00139351
Bureau of Prisons
Health Services
PPDs
Reg #: 76318-054
Inmate Name: EPSTEIN, JEFFREY EDWARD
Admix u
Jscation
07/06/2019 21:39
Right Forearm
Orig Entered: 07/06/2019 21:43 EST
Total: 1
Provider
PA-C
PA-C
Reading•
Jnduratioq
Provider
07/09/2019 12:47
0 mm
. MLP
Orig Entered: 07/09/2019 12:47 EST
. MLP
Generated 08/10/2019 11:02 by
RN/10P/10C
Bureau of Prisons • NYM
Page 1 of 1
CONFIDENTIAL
SDNY_00009447
EFTA00139352
76318.054
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. Data
07/30/19
14:21
Exp. Dam
07/31/19
10 01
NYM
122148-
NYM
MD
Inject regular Insulin subcutaneously per
sliding scale: Mice daily •"pIll line" for 7
days
Insulin Reg (10 ML) 100 UNITS/ML In)
PRN
Ord. Dale
07/31119
10:00
Exp. Dale
08107/19
09:59
NYM
122160-
NYM
Beaudown, Robert MD
Inject regular insulin subcutaneously par
sliding scale: each morning for 7 days "'pin
One"'
InsoLn Reg (10 ML) 100 UNITS/ML In;
PRN
_
Providers: YJ =
Documentation Codes: ORD = Order I NI = Dose Not Indicated
Registration U. 76318-054
Pt Name. EPSTEIN, JEFFREY
DOS: 01/20/53
Report information is current as 04 the date and time of printing. 08/10/2019 11:02 EST
CONFIDENTIAL
SDNY_00009448
EFTA00139353
76318.054
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. Dale
07/31/19
10.00
Exp. Dare
09/07/19
09.59
MD
Infect regular insulin subcutaneously per
sliding scale: each morning for 7 days —Mg
line—
NYM
122160-
NYM
Insulin Reg (10 ML) 100 UNITS/ML Inj
PRN
Providers: YJ
Documentation Codes: ORD = Order I NI = Dose Not Indicated
Registration ft 76318-054
Pt. Name. EPSTEIN, JEFFREY
008: 01/20/53
Report information is current as of the dale and time of printing. 08/10/2019 11d2 EST
CONFIDENTIAL
SDNY_00009449
EFTA00139354
Bureau of Prisons
Health Services
Devices and Equipment
Start Date: 07/07/2019
Stop Date:
08/10/2019
Reg #:
76318-054
Inmate Name: EPSTEIN, JEFFREY EDWARD
Pevice/Eauioment
Start Date
Stoo Date
Pate Returned
Obtained From
Comments
C-Pap
07/30/2019 14:05 EST
MD 07/30/2019
Personal
MACHINE.
SERIAL #: P11312813B1ED.
Total: 1
Generated 08/1012019 11:02 by
RN/1OPADC
Bureau of Prbons NYM
Page 1 of 1
CONFIDENTIAL
SDNY_00009450
EFTA00139355
Bureau of Prisons
Health Services
Pain Management
Begin Date: 07/07/2019
End Date:
08/10/2019
Reg #:
76318-054
Inmate Name: EPSTEIN. JEFFREY EDWARD
QM
Jnterventiort
Pain Quality
Location
Pre Post
Provider
07/12/2019 13:25
Shooting
Back-Middle
5
MD
Orig Entered: 07/12/2019 13:28 EST
MD
Generated 08/10/2019 11:02 by
RNAOP/I0C
Bureau of Prisons - NYM
Page 1 of 1
CONFIDENTIAL
SDNY_00009451
EFTA00139356
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:
Inmate Name
Generated 07730/2019 14:57 by
MD
Health Service Staff
76318-054
07/30/2019
Reg#
Date
MD
Bureau of Prisons - NYM
Page 1 of 1
CONFIDENTIAL
SDNY_00009452
EFTA00139357
Bureau of Prisons
Health Services
Allergies
Reg #: 76318-054
Inmate Name: EPSTEIN, JEFFREY EDWARD
Minn
Date Noted
Reaction
No Known Allergies
07/06/2019
Orig Entered: 07/06/2019 21:40 EST
PA-C
Total: 1
Generated 08/10/2019 11:02 by
Bureau of Prisons • NYM
Page 1 of 1
CONFIDENTIAL
SDNY_00009453
EFTA00139358
Bureau of Prisons
Health Services
Patient Education Assessments & Topics
Reg #: 76318-054
Inmate Name: EPSTEIN, JEFFREY EDWARD
Assessments
Assessment
Learns Best By
Primary Language
07/09/2019
Speaking/Listening
English
Orig Entered: 07/09/2019 12:52 EST
Total: 1
Bate Initiated
07/30/2019
Format
Counseling
Orig Entered: 07/30/2019
07/30/2019
Counseling
Orig Entered: 07/30/2019
07/28/2019
Counseling
OrIg Entered: 07/28/2019
07/28/2019
Counseling
Orig Entered: 07/28/2019
07/24/2019
Counseling
Orig Entered: 07/24/2019
07/24/2019
Counseling
Orig Entered: 07/24/2019
07/23/2019
Counseling
Orig Entered: 07/23/2019
07/23/2019
Counseling
Orig Entered: 07/23/2019
07/14/2019
Counseling
Orig Entered: 07/14/2019
07/12/2019
Counseling
Handout/Tooic
Access to Care
13:33 EST
Plan of Care
13:34 EST
Plan of Care
07:22 EST
Plan of Care
20:30 EST
Access to Care
13:23 EST
Preventive Health
13:23 EST
Access to Care
09:04 EST
Plan of Care
09:04 EST
Diagnosis
18:11 EST
Diagnosis
Generated 08/10,2019 11:02 by
RaltIOP/IDC
Years of Education Barriers To Education
12
None
Topics
Bureau of Prisons • NYM
Outcome
Verbalizes Understanding
Verbalizes Understanding
Verbalizes Understanding
Verbalizes Understanding
Verbalizes Understanding
Verbalizes Understanding
Verbalizes Understanding
Verbalizes Understanding
Verbalizes Understanding
Verbalizes Understanding
Provider
provider
Page 1 of 2
CONFIDENTIAL
SDNY_00009454
EFTA00139359
Reg #: 76318-054
Inmate Name: EPSTEIN, JEFFREY EDWARD
TOINE0NNO3
95460000-MOS
Topics
Format
Pate Initiated
Handout/rot:4c
Outcome
Orig Entered: 07/12/2019 13:33 EST
Total: 10
Generale0 08/10/2019 11:02 by
RN/IOP/1OC
Bureau of Prisons - NYM
Page 2 of 2
EFTA00139360
Bureau of Prisons
Health Services
Blood Glucose
Begin Date: 07/07/2019
End Date:
08/10/2019
Reg #:
76318-054
Inmate Name: EPSTEIN, JEFFREY EDWARD
(Reference Range: Random or Fasting 70 - 100, 2 hour post-prandial 70 - 140)
D.abit
Time
Value
UPS
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 08/10/2019 11:02 by
RN/1OPADC
Bureau of Pitons - NNW
Page 1 of 1
CONFIDENTIAL
SDNY_00009456
EFTA00139361
Bureau of Prisons
Health Services
Health Problems
Reg #: 76318-054
Inmate Name: EPSTEIN, JEFFREY EDWARD
Description
Hyperlipidemia, unspecified
07/12/2019 13:48 EST
Sleep apnea
07/12/2019 13:56 EST
Essential (primary) hypertension
07/30/2019 13:13 EST
BY HX.
Constipation, unspecified
07/09/2019 12:58 EST
Low back pain
07/12/2019 13:30 EST
MLP
Neuralgia and neuritis, unspecified
07/12/2019 13:30 EST
MD
MD
MD
MD
MD
No Diagnosis
07/09/2019 10:28 EST
PhD/Chief
Psychologist
Prediabetes
07/30/2019 13:26 EST
Injury, unspecified
07/23/2019 09:04 EST
. MLP
R/O self inflicted injuries.
Body mass index (BMI) 27.0-27.9, adult
07/30/2019 13:14 EST
Total: 10
MD
MD
Axis Code TYDe
Current
Cada
J)iag. Date Status
Status Date
ICD-10
E785
07/12/2019 Current
ICD-10
G4730
07/12/2019 Current
ICD-10
110
07/30/2019 Current
ICD-10
K5900
07/09/2019 Current
ICD-10
M545
07/12/2019 Current
ICD-10
M792
07/12/2019 Current
I DSM-IV
No Dx
07/09/2019 Current
ICD-10
R7303
07/30/2019 Current
1CD-10
T1490
07/23/2019 Current
ICO-10
Z6827
07/30/2019 Current
Generated 013/10/2019 11:02 by
RN/1O13/1DC
Bureau of Prisons - NYM
Page 1 of 1
CONFIDENTIAL
SDNY_00009457
EFTA00139362