EFTA00059443.pdf

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: N M Cosigned by MD on 07/11/2019 22:41. Burew W ftilscm - WM EFTA00059443 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 Hyperlipldemia, unspecified HYPERTRIGLYCERIDEMIA Sleep apnea Essential (primary) hypertension BY HX. Constipation, unspecified Low back pain Neuralgia and neuritis, unspecified No Diagnosis Prediabetes Injury, unspecified R/O self Inflicted injuries. Body mass index (BMI) 27.0-27.9, adult atatua Current Current Current Current Current Current Current Current Current Current Medications: All medications to be continued until evaluated by a physician unless otherwise In Bolded drugs required for transport. Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take one capsule (100 MG) by mouth twice Docusate Sodium 100 MG Cap Exp: 01/22/2020 SIG: Take one capsule (100 MG) twice daily by of water Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML Exp: 10/28/2019 SIG: shake well take 10mI by daily AS NEEDED Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by OTCs: Listing of all known OTCs this inmate is currently taking. None Pending Appointments lorded. ily for 30 days th with plenty th twice uth with food Dale lima Activity Provider 07/24/2019 00:00 Clinical Encounter Optometrist 01/07/2020 00:00 Chronic Care Visit Mid-Level Provider 07/01/2020 00:00 Chronic Care Visit Physician 01 07/09/2020 00:00 PPD Administration Nurse Pending Non-Medication Orders: Order Order Date Frequency EKG 07/06/2019 One Time Focal Occult Blood 07/06/2019 One Time TB Clearance: Yes Last PPD Date: 07/09/2019 Last Chest X-Ray Date: TB Treatment TB Follow-up Recommended: No Sickle Cell: Sickle Cell Trait/Disease: No Dualism Retails 66 y/o male 3 different stools Induration: 0mm Results: Sx free for 30 days: Yes Generated 08/10/2019 07:00 by RN Bureau of Prisons - NYM Page 1 of 2 EFTA00059444 Reg 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD SENSITIVE BUT UNCLASSIFIED — This Won-nation Is confidential and must be appropriately safeguard d. 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 Phone Number. 6468366300 Address 1: 150 PARK ROW Address 2: City/State/Zip: NEW YORK, New York 10007 Namerfltle of Person Completing Form: RN Dal 08/10/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 DOB: 01/20/1953 Generated 08110/2019 07:00 by RN Bureau al Prisons - NNW Page 2 of 2 EFTA00059445 Bureau of Prisons Health Services Vitals All Begin Date: 07/07/2019 End Date: 08/10/2019 Rog #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Temperature: Data Tiffin Fahrenheit Celsitot Location Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral Orig Entered: 07/24/2019 13:14 EST MLP 07/23/2019 06:30 NYM 97.5 36.4 Oral Orig Entered: 07/23/2019 08:33 EST MLP 07/09/2019 12:49 NYM 97.3 36.3 Oral Orig Entered: 07/09/2019 12:51 EST MLP Pulse: 12lita Time Rate Per Minute I ocation 07/30/2019 13:02 94 Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:40 88 Via Machine Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:30 87 Via Machine Orly 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 Via Machine Orly Entered: 07/24/2019 13:14 EST . MLP 07/23/2019 06:30 92 Via Machine Orig Entered: 07/23/2019 08:33 EST . MLP 07/09/2019 12:49 82 Via Machine Orig Entered: 07/09/2019 12:51 EST MLP .MLP .MLP .MLP Rhythm Provider MD MD MD MO MD MD RN RN 7! RN RN Regular Regular Regular Respirations: Bata Inn Rate Per Minute Provider 07/30/2019 09:30 NYM 12 MD Orly Entered: 07/30/2019 12:59 EST MD 07/28/2019 20:28 NYM 14 RN Orlg Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 NYM 14 RN Orig Entered: 07/28/2019 06:58 EST RN 07/23/2019 06:30 NYM IIWMLP Orly Entered: 07/23/2019 08:33 EST . MLP 07109/2019 12:49 NYM 16 . MLP Orig Entered: 07/09/2019 12:51 EST . MLP .MLP .MLP Generated O8V10/2019 11:02 by Bureau of Prisons - NYM Pogo 1 or 3 EFTA00059446 Begin Date: 07/07/2019 Reg #: 76318-054 End Date: 08/10/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Blood Pressure: Date lima 07/30/2019 13:02 NYM Orig Entered: 07/30/2019 09:40 NYM Orig Entered: 07/30/2019 09:30 NYM Orig Entered: 07/28/2019 20:28 NYM Orig Entered: 07/28/2019 06:57 NYM Orig Entered: 07/24/2019 13:12 NYM Orig Entered: 07/23/2019 06:30 NYM Orig Entered: 07/09/2019 12:49 NYM Orig Entered: Value ) °cation 114/84 Left Arm 07/30/2019 13:04 EST 125/60 Right Arm 07/30/2019 13:04 EST 108/86 Left Ann Sitting 07/30/201912:59 EST 157/91 07/28/2019 20:29 EST 138/80 07/28/2019 06:58 EST 132/89 Right Arm 07/24/2019 13:14 EST 140/85 Right AIM 07/23/2019 08:33 EST 117/66 Right Arm 07/09/2019 12:51 EST Position Standing Standing Cuff Size provider MD MO MD RN Beaudouin, Robert MD EMINIMMD MIMI"( MD -U RN RN Sitting Adult-regular MLP MLP Sitting Adult-regular MLP MLP Sitting Adult-regular Ma MLP MLP Blood Glucose: Thus Time Value imgldll Tyne Regular insulin provider 08/04/2019 08:30 156 Non-Fasting Ortg Entered: 08/04/2019 09:08 EST 08/02/2019 06:30 97 Non-Fasting Orig Entered: 08/02/2019 08:16 EST MLP 08/01/2019 06:30 103 Non-Fasting Orig Entered: 08/01/2019 09:00 EST alla MLP 07/31/2019 06:15 108 Non-Fasting Orig Entered: 07/31/2019 08:36 EST Ma MLP Sa02: Nit /1mi ValuerAl Ak 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 08:57 NYM 98 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 =M. MLP 07/23/2019 06:30 NYM 96 Room Air MLP Orig Entered: 07/23/2019 08:33 EST MLP 07/09/2019 12:49 NYM 97 Room Air ■ Orig Entered: 07/09/2019 12:51 EST MLP RN provider MD RN Height Generated 08/10/2019 11:02 by Bureau of Parsons NYM MLP MD RN RN RN RN MLP MLP MLP Page 2 of 3 EFTA00059447 Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Data II= Inches Cm Provider 07/09/2019 12:49 NYM 70.0 * 177.8 MLP Orig Entered: 07/09/201912:51 EST a MLP Weight: D.A.Ltt Emit 1n Kg Weicc .In1 Provider 07/30/2019 09:30 NYM 194.2 88.1 ~nip Orig Entered: 07/30/2019 12:59 EST 07/09/2019 12:49 NYM 194.4 88.2 Orig Entered: 07/09/2019 12:51 EST a MLP MD MLP Generaled 08/10/2019 11:02 by Bureau of Prisons - NYM Pass Set 3 EFTA00059448 Bureau of Prisons Health Services PPDs Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD j,ocation 07/06/2019 21:39 Right Forearm Orig Entered: 07/06/2019 21:43 EST Total: 1 Provider C Reading• Induration 07/09/2019 12:47 0 mm INS MLP Odg Entered: 07109/2019 12:47 EST MI MLP Generated 08/10/2019 11:02 by RNAOP/IDC Bureau of Prisons - NYM Page I 011 EFTA00059449 76316454 EPSTEIN, JEFFREY Medication Orders ob. 07r10/19 1421 Exp. Dab 07(31119 1001 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 NYM 122148- NM/ Infect neulz: Insulin st bcute-toousty per altding ocr,..:J: bock° Cary ^•p'J Ilna^• for 7 days tuff) Reg (10 IC)1 CR istiersaa rm PRN • Oct Date AID 07f31119 1000 bjaa tegul.ra tnacdln aubcutanooLraty par Fes. Data slItEng scale: oath morning for 7 days "'PM 08/07/19 Ono — 09S9 NYM 122160- NYM Lnu:n Reg (00 M-)100 lINITS/ML Lnj PRN -PlovideTsn-YJ = Documentation Codes: ORO = Order I NI = Dose Not Indcated Regdeabon St 76318-054 Pt. Name: EPSTEIN, JEFFREY DOB: 0112043 Report infornallon Is current as of the 4810 MCI tune of printing: 08/100019 11:02 EST EFTA00059450 76318-054 Ord. Dato 07(31119 1090 Esp. On 01/07119 0959 MYM 172160. MYM EPSTEIN. JEFFREY Medication IC/ Ir*st tesailas hmu5n subcutaneously por sCdIng scale: each moralni; for 7 days "'pw Cne"' Ustaat Reg (10 Ml..) 100 UNITSIMI. Medication Administration Record AUGUST 2019 limo 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 PAN Provider:: YJ =M" Documentation Codes: ORD = Cider I NI r-. Dose Not Indicated Reg's-Batton P: 76318-054 Pt. Name: EPSTEIN. JEFFREY DOB: 01/20/53 Raport Inftxmalion is amtell es of the data and limo ot printing- 08/10/2019 11:02 EST EFTA00059451 Bureau of Prisons Health Services Devices and Equipment Start Date: 07/07/2019 Stop Date: owl012019 Reg #: 76315-054 Inmato Name: EPSTEIN, JEFFREY EDWARD Auks/Equipment Start Date Stop Dat0 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 0811012019 11:02 by RNAOPADC Bureau of Prisons - NYM Page 1 of 1 EFTA00059452 Bureau of Prisons Health Services Pain Management Begin Date: 07/07/2019 Reg #: 76318-054 End Date: 08/10/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD lagg intervention 07/12/2019 13:25 MEDROL DOSE PACK Orig Entered: 07/1212019 13:28 EST Pain Quality Shooting MD Location Ea Post Provider Back-Middle 5 MD Generated 09/102019 11:02 by RN/IOPADC Bureau of Prisons - NYM Page 1 of 1 EFTA00059453 Bureau of Prisons Health Services Modified Diet Re uest 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: EPSTEIN, JEFFREY EDWARD Inmate Name Health Service Staff 76318-054 07/30/2019 Reg# Date Generated 07/3012019 14:57 by MD Bureau of Prisons NYM Page 1 of 1 EFTA00059454 Bureau of Prisons Health Services Allergies Reg #: 78318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Allergy Pate Noted Reactlog No Known Allergies 07/06/2019 Orig Entered: 07/06/2019 21:40 EST Total: 1 Generated 08/10/2019 11:02 by Bureau of Prisons • NYM Page 1 of 1 EFTA00059455 Bureau of Prisons Health Services Patient Education Assessments & Topics Reg IS: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Assessments Assessment Learns Rest Ay primary I anguage Years of Education FiarfietSigntucatign 07/09/2019 Speaking/Listening English 12 None 0rig Entered: 071091201912:52 EST M. Total: 1 pate Initiated Format Handout/Toplq 07/3012019 Counseling Access to Care Orig Entered: 07/30/2019 13:33 EST 07/30/2019 Counseling Plan of Care Orle 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 (prig Entered: 07/28/2019 20:30 EST 07/24/2019 Counseling Access to Care Orig Entered: 07/24/2019 13:23 EST ME. 07/24/2019 Counseling Preventive Health Ofig Entered: 07/24/2019 13:23 EST a 07/23/2019 Counseling Access to Care Orig Entered: 07/23/2019 09:04 EST -07123/2O1-9--- Counsaling 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 Topics Outcome Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Provider Provider Generated 08/10/2019 11:02 by RN/IOPI1DC Bureau of Prisons - NYM Page 1 of 2 EFTA00059456 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Topics Pate Initiated Format HandoutfTooic Outcome Provider Ortg Entered: 07/12/2019 13:33 EST Total: 10 Generated 08/1012019 11:02by RNnOWIDC Bureau of Prisons • NYM Page 2 oft EFTA00059457 Bureau of Prisons Health Services Blood Glucose Begin Date: 07/07/2019 Reg #: 76318-054 End Dato: 08/10/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD (Reference Range: Random or Fasting 70 - 100, 2 hour post-prandial 70 - 140) DAR lama Yalua 08/04/2019 08:30 NYM 156 Orig Entered: 08/04/2019 09:08 EST 08/02/2019 08:30 NYM 97 Orig Entered: 08/0212019 08:16 EST 08/01/2019 06:30 NYM 103 Orig Entered: 08/01/2019 09:00 EST 07/31/2019 08:15 NYM 108 Orig Entered: 07/31/2019 08:36 EST Total: 4 IY1211 Non-Fasting RN Non-Fasting =11 MLP Non-Fasting MLP Non-Fasting MEM MLP Comments Generated 08/10/2019 11:02 by RN/IONDC Bureau of Prisons - NYM Page 1 of 1 EFTA00059458 Bureau of Prisons Health Services Health Problems Reg 01: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Descnotion Axis Code I'm', Code Diagialia Status. Current HyperilpIdemla, 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 1.1.1 PhD/Chief I DSM-IV No Dx 07/09/2019 Current syc o ogis Prediabetes 07/30/2019 13:26 EST MD ICD-10 R7303 07/30/2019 Current Injury, unspecified 07/23/2019 09:04 EST a MLP ICD-10 T1490 07/23/2019 Current RIO 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 08/10201911:02 by RNIIOP/iOC Bureau of Prisons - NYM Page 1 or 1 EFTA00059459 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/12/2019 13:10 Provider: Reg #: 76318.054 Facility: NYM 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 OL HYPERT 800 . MEDS HX OF O MACHINE. STATES THE L4 - L5 SEVERE LOWER EXTREMITIES. SURGICAL HX: NONE MENTAL HEALTH HX: Pain: Yes Pain Assessment Date: Location: Quality of Pain: Pain Scale: Intervention: Trauma Date/Year: Injury: Mechanism: Onset: Duration: Exacerbating Factors: Relieving Factors: Reason Not Done: Comments: MD HITE MALE WITH HX OF CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE EIR GI SIDE EFFECTS. UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. Y HAS SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE 07/12/2019 13:25 Back-Middle Shooting 5 MEDROL DOSE PACK 5+ Years 5+ Years NO EXERCISE MEDROL DOSE PACK 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 Ho: Appears Obese Genet/tied 07/12/2019 bk20 by Bureau of Prisons • NYM Page 1 of 3 EFTA00059460 Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Encounter Date: 07/12/2019 13:10 Provider: Reg ft 76318.054 Race: WHITE Facility: NYM 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 B Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back Yes: Tenderness ithi Neurologic 41) Cranial Nerves (CN) Yes: W ASSESSMENT: Constipation, unspecified. K5900 - Current 0: 4 0,120 Motor Systemn Normal Limits -General Yes: Normal Exam Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current 0 le t Sleep apnea, G4730 - Current PLAN: New Medication Orders: Bra 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 MethylPREDNISolone 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 07/12/2019 14:20 by MD Bureau of Prisons • NYM Page 2 of 3 EFTA00059461 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM l 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 Formal 07/12/2019 Counseling Copay Required:No TelephoneNerbal Order: Completed by Handout/Topic Diagnosis Cosign Required: No n 07/12/2019 14:20 Provider Outcome Verbalizes Understanding Generated 07/12/2019 14:20 by MD Bureau of Prisons NYM Page 3 of 3 EFTA00059462 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 Dale: 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 OL HITE MALE WITH HX OF HYPERT CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , . STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS 9, EIR GI SIDE EFFECTS. HX OF O iS)14ii LIVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. '•1 q? HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE Y HAS L4 - L5 SEVERE SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMI S. 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 Page 1 or 3 EFTA00059463 Inmate Name: EPSTEIN. JEFFREY EDWARD Reg )4: 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 d.Rhythm (RRR). Normal S1 and S2 No: M/R/G Abdomen Auscultation Yes: Normo-Active 8 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: EK.# Ke_dkation Order Date Magnesium Hydroxide Susp 07/12/2019 13:10 Disposition: Prescriber Order 30 CC Orally - T o Times a Day PRN x 2 day( ) Indication: Constipation, unspecified MethylPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 AS DIRECTED Pack 21 tab) 6 day(s) Indication: Neuralgia and neuritis, unspecified ly - daily x Generated 07/12/2019 14'20 by MD Bureau of Prisons • NYM Page 2 of 3 EFTA00059464 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg If: 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 07/12/2019 Counseling Copay Required: No TelephoneNerbal Order: Completed by Handout/Topic Diagnosis .,- . Cosign Required: No --.) i . D.,•n 07/12/2019 14:20 Pr_ovides, Outcome Verbalizes Understanding Generated 07/12/2019 14 20 by MO Bureau of Prisons • NYM Page 3 of 3 EFTA00059465 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 71 Date of Birth: 01/20/1953 Sox: M Race: Encounter Date: 07/14/2019 17:36 Facility N 8-054 Amendment mado to this note by MD on 07/14/2019 18:11. Bureau of Prrsons - NYM EFTA00059466 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Note Date: 07/12/2019 09:08 Sex: Provider. MD Reg /t: Facility: Unit: 76318-054 NYM ZO5 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: Rx# Medication Dccusate Sodium Capsule Indication: Constipation, unspecified Discontinued Medication Orders: adt Medication 121757-NYM Bisacodyl E.C. 5 MG TAB Order Date 07/12/2019 09:06 Order Date 07/1212019 09:06 Discontinue Type: When Pharmacy Processes Discontinue Roason:discontinue Indication: Copay Required: No TelephoneNerbal Order No Completed by Cosign Required: No MD on 07/12/2019 09:10 prescriber Order TAKE ONE 1 r t MG CAP Orally - Two Times Day x 30 day(s) c ibe Take one tatAit (5 MG) by mouth at bedtime AS NEEDED for 10 days Generated 07/12/2019 09:10 by MD Bureau of Prisons - NYM Page 1 of 1 EFTA00059467 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Note Date: 07/07/2019 00:17 Provider- MD Reg #: 76318-054 Facility: NYM Unit: ECG Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider. MED CL:1 NO CCC APPT. Discontinued Laboratory Requests: Details Frequency Lab Tests-H-Hemoglobin AlC One Time Lab Tests-C-CBC w/diff Lab Tests-L-Lipld Profile Lab Tests-C-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Rellex to Microscopic Additional Information: 66 y/o male, elevated BP Labs requested to be reviewed by: MD New Laboratory Requests: DataHa Chronic Care Clinics-Diabetic-CBC w/diff 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-Comerehensive Metabolic Profile (CMP) New Radiology Request Orders: Details Frequency End aatft Due Pate General Radiology-Chest-2 Views One Time 07/25/2019 Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH NO PMHX REFERRED FOR ROUITNE CXR. MD Copay Requlrod:No TelephoneNerbal Order: No Completed by Cosign Required: No MD on 07/07/2019 00:30 Due Date 08/05/201900:00 R• Frequency Rue Date Priority One Time 07/25/2019 00:00 Routine Edo* Ftouline Generated 07/072019 00:30 by MD Bureau of Prisons • NYM Panto% 1 EFTA00059468 Bureau of Prisons Health Services History & Physical Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Dale: 07/09/2019 12:35 Provider M Race: WHITE BIM MLP Reg #: 78318464 Facility: NYM Unit r 1 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): 104- Mate Sexual Partners (Last 5 Yrs): 0 Condom Use: Sometimes Soxual 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 Generated 07/09/2019 13:03 by M. MLP Bureau of Prisons - NYM 1el 13 EFTA00059469 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: Date of Birth: 01/20/1953 Sex: M : WHITE Facility: Encounter Date: 07/09/2019 12:35 Provider . MLP Unit 7; 18-054 HIV History: When Tested: 2019 Test Result: Negative Whon 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 Gantt-aux' 07/022019 13:03 by an Bureau of Prisons NYM 2of 13 EFTA00059470 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 MB MLP Unit: 14 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: N/A Dental Condition: Denied Generated 07/09/2019 13:03 by MLP Buttenu of Prisons-NYM Page 3 ad 13 EFTA00059471 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/09/2019 12:35 Provider: MLP : WHITE Reg #: 76318-054 Facility: NYM Unit 1101 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: Generated 07,09/2019 13:03 by Ea MLP Bureau of Prisons - NYM Page 4 of 13 EFTA00059472 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/09/2019 12:35 Provider: 111.1. MLP Reg #: 76318064 Facility: NYM 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:MEI'. 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: Routo: 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 Generated 07/09/2019 13:03 by MLP Bureau of Prisons - NYM 5d 13 EFTA00059473 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: : WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider. IMIll ekILP Unit: F01 Immunization Date: Provider: IMIE. MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Varicella Series Administration: History Unknown, Not Administered Documented Date: 07/09/201912:51 EST Immunization Date: Provider: NEB MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Temperature: pa a Time Fahrenheit celsjua 1,0cation Provider 07/09/2019 12:49 NYM 97.3 36.3 Oral MLP Pulse: Mgt Time Rate Per Minute Location Rfivthrrt Provider 07/09/2019 12:49 82 Via Machine Regular MLP Respirations: io 07/09/2019 Time Rate Per Minute Provider 12:49 NYM 16 MLP Blood Pressure: PAO Brae yawn Location. Position Cuff Size Provider 07/09/2019 12:49 NYM 117/66 Right Arm Sitting Adult-regular MLP SaO2: to Time Value(%) Ali Provider 07/09/2019 12:49 NYM 97 Room Air MLP Height: Data Time Inches Cm Provider 07/09/2019 12:49 NYM 70.0 177.8 MLP Generated 07/092019 13.03 by a MLP Bureau of Prisons - NYM Pali 6 of 13 EFTA00059474 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: ea: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: . MLP Unit: H01 Date Time in_cheS _Ca Provider Weight: Data Time 1.bs Ka Waist Circum Emitter 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: Pate gd Yrs OccUrtation Learns Best By Peqa if 07/09/2019 12 Balker 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: Numbor of Siblings: 1 Significant Illnesses: Comments: Past Hospitalization: on Speaking/Listening English None Reason Location Acute Appendicitis Mount Sinai Hospital Complications: None Comments: Head: Normal: Yes Comments: When 1990 Ger-waled 07/C9/2019 13.03 by MLP Bureau of Prisons • NYM Page 7 of 13 EFTA00059475 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg*: 318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: Encounter Date: 07/09/2019 12:35 Provider: MLP Unit 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 Fund' 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 Near Vision: OD: OS: OU: OD: OS: Ishihara 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: Generated 07/09/2019 13:03 by tat? Bureau of Prisons - NYM Page 6 of 13 EFTA00059476 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01120/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/201912:35 Provider: Ia. MLP Unit: 1 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-Xll: 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: Comments: No Generated 07/09/2019 13.03 by MLP Bureau of Prisons - NYM Page 9 of 13 EFTA00059477 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Encounter Date: 07/09/2019 12:35 Provider: Thorax: Contour Normal:Yes Increased AP Diameter: No Asymmetrical Expansion:No Lungs Clear: Yes Wheezes: No Crackles: No Rhonchl: No Rates: No Accessory Muscle Use: No Comments: Spine: Deformity: No Full ROM:Yes Tondernoss:No Comments: Cardiovascular: RRR: Yes Normal S1/S2: Yos Murmurs: No Carotid Bruits:No JVD: No Arteries: Right Left Radial: Femoral: Dorsalis Pedis: Post. Installs: Comments: Reg 4: 76, 18-054 Race: WHITE Facility: MLP Unit: HO Goaerale\7 07/09/2019 13:03 by MLP Bureau of Prisons • NYM Page 10 of 13 EFTA00059478 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 7 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: Encounter Date: 07/09/201912:35 Provider: MLP Unit 18-054 1 Abdomen: Normal Contour:Yes Scaphold: No Obese: No Gravid: No Hernias: No Bruits: No Masses:No Scars: No Tenderness: No Organomogaly: No Active Bowel Sounds: Yes Comments: Extremities: Nails Clubbing: No Nails Cyanosis: No 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: Fight Left Arm: Log: Full ROM: Right Arm: Yes Yee Leg: Yes Yes Comments: Gene:rood 07/0912019 13:03 by EIM. MLP Etwoau of Prisons NYM P. 11 of 13 EFTA00059479 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg it 76 18-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: Encounter Date: 07/09/2019 12:35 Provider. a MLP Unit: Reflexes: flight ken 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: Item 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 07/09/2010 13:03 by . MLP Bureau of Prisms - NYM Page 12 of 13 EFTA00059480 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #. 76318-054 Date of Birth: 01120/1953 Sex: : WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider Unit: H01 Cleared For Food Services: Yes Health Problems Newly Identified During This Encounter: Health Problem Constipation, unspecified - Current - Now Medication Orders: # Medication. Bisacodyl E.C. Tablet Indication: Constipation, unspecified Disposition: Follow-up at Sick Call as Needed Order Date altadindfli 07/09/2019 12:35 5 mg Ordy et bedtime PFtN x 10 day(s) Instructed inmate how to obtain medical, dental, and mental health care. Copay Required:No Cosign Required: Yes TelophoneNerbal Order No Completed MLP on 07/09/2019 13:03 Requested to be cosigned by NM= MD. Cosign documentation will be displayed on the following page. Generated 07/09/2019 13:03 by MEIMLP Bureau of Prisons • NYM Pio 13 of 13 EFTA00059481 Bureau of Prisons Health Services Vision Screens Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Vision Screen on Blindness: 07/09/2019 12:52 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 R: R: L: L: Color Test Tonomotry: R: L: Comments: Needs evaluation with optometrist. OrIg Entorod: 07/09/2019 12:54 EST Ma MLP Generated 08110/2019 11:02 by Bureau of Prisons - NYM Pap 1 el I EFTA00059482 Bureau of Prisons Health Services Immunizations Begin Date: 07/07/2019 Reg #: 76318-054 End Date: 08/10/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Immunization Hepatitis A and B (TwinRx) Orig Entered: 07/09/2019 12:51 EST Measles/Mumps/Rubella Series Orig Entered: 07/09/2019 1a51 EST Smallpox Series Orly Entered: 07/09/2019 12:51 EST Tetanus Orig Entered: 07/09/2019 12:51 EST Varicella Series Total: 5 Orig Entered: 07/09/2019 12:51 EST Immuolzalloanslle Administered. Location Dosage Drug Mfg, History Unknown MLP History Unknown • MU' History Unknown MLP History Unknown MLP History Unknown MLP Txp Date Generated 08/10/201911:02 by RN/IOP/IDC Bureau of Prisons - NYM Page 1 of 1 EFTA00059483 Bureau of Prisons Health Services Medical Duty Status Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD ?Tr , • Houslog•Stattre: tt" tr - . a. confined to the living quarters except _meals pill line _treatments Exp. Date: Exp. Date: Exp. Date: Exp. Date: Ptinta tli;g4DniiitsTSel1/2 :ttri: all spoil:4 Exp. Date: wstuhutfting: _upper body lower body Exp. Date: ...ctsychavascular exercise: _running _jogging _walking softball Exp.. Date: on complete bed rest:.. .. bathroom privileges only X cell: eeN on first floor single cell X lower bunk airborne infection isolation other ' 'other: _football _basketball _handball stationary equipment • falergiffinagra urS areigiga niiiiig •';' Equipment Start Date C-Pap 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. O W m tali Cleared for Food Service: Yes X No Restrictions Comments: N/A 1rtatts:Iriart Health Services Staff • Exp. Date: End Date 10/09/2019 r;:dutuSk..;.t. MD 07/30/2019 Date elum Date Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 76318.054 Quarters: Z04 ALL EXPIRATION DATES' RE AT 24:00 • ...-44k;:.:4":, Generated 0811012019 11:02 by Bureau d Prisons - NYM Page I oil EFTA00059484 Bureau of Prisons Health Services Medical Duty Status Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD confined to the living quarters except _meals _pill line treatments Exp. Date: on complete bed bathroom privileges only Exp. Date: X cell: cell on fi t floor. single cell X lower bunk airborne infection isolation Exp. Date: Exp. Date: other. effOrahrffiallo it idrictrOrigfrnitag,:frit:FL . 5?.i.t:' all sports„;:' weigtitfifting: upper body lower body -cardioyascular exercise: running _jogging _walking softball football basketball _handball _stationary equipment Exp. Data: Exp. Date: Exp. Date: Exp. Date: 10/09/2019 1.1. WI :a '.•••••;:' haverkgfcMirgaa61PIAglirfirOWerplass'esstoliyak&itaiW: ti Wk.,..124satta ki Aratatjai sitaterfa:r 3/47rt,WA Cleared for Food Service: Yes X No Restrictions Comments: N/A Health Services Staff MLP 07/09/2019 Date Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 33: 76318-054 Quarters: Z04 ALL EXPIRATION DATES ARE AT 24:00 Generated 08/10/2019 11:02 by BUIVIU or Prisons • NYM Page 1 of 1 EFTA00059485 Bureau of Prisons Health Services Medication Summary Historical Complex: NYM—NEW YORK MCC Inmate: EPSTEIN, JEFFREY EDWARD Begin Date: 07/07/2019 End Date: 0B/10/2019 Reg #: 76318-054 Quarter: Z04-206LAD 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. Ili MLP Start: 07/09/19 Exp: 07/19/19 D/C: 07/12/19 Pharmacy Dispensings: 10 TAB i 32 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 Pharmacy Dispensings: 60 CAP ir 29 days Docusate Sodium 100 MG Cap Take one capsule (100 MG) twice daily b mouth with plenty of water Rx#: 122084-NYM Doctor. MD Start: 07/26/19 Exp: 01/22/20 Pharmacy Dispensings: 30 CAP In 15 days Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML shake well take 2 tablespoonful twice dal b mouth Rx#: 121835-NYM Doctor. MD Start: 07/12/19 Exp: 07/14/19 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 methyiPREDNISolone 4 MG Tab ( 21 count Pack) Take the tablet by mouth as directed fbc#: 121836-NYM Doctor. Start: 07/12/19 Exp: 07/18/19 methylPREDNISolone 4 MG Tab ( 21 count Pack) Take the tablet by mouth as directed Rx#: 122149-NYM Doctor: Start: 07/30/19 Exp: 08/05/19 MD MD Pharmacy Dispensings: 473 ML in 29 days Pharmacy Dispensings: 473 ML in 11 days Pharmacy Dispensings: 21 tab in 29 days Pharmacy Dispensings: 21 tab In 11 days Generated 08/10/201911:02 by Bureau of Prisms - NYM Page 1 of 2 EFTA00059486 Complex: NYM—NEW YORK MCC Inmate: EPSTEIN. JEFFREY EDWARD Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Quarter. Z04-206LAD Active Prescriptions Omega 3 (Vascepa) 1 GM Capsule Take two capsules (2 GM) twice daily b mouth with food Rx#: 121885-NYM Doctor: MD Start: 07/17/19 Exp: 01/13/20 Pharmacy DispensIngs: 180 Cap in 24 days Insulin Reg (10 ML) 100 UNITS/ML Inj Inject regular Insulin subcutaneous/ er slidin 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 11 days Insulin Reg (10 ML) 100 UNITS/ML Inj Inject regular insulin subcutaneous) er sliding scale: each morning for 7 days —*pill lino— "'pill line Rx#: 122160-NYM Doctor: MD Start: 07/31/19 Exp: 08/07/19 Pharmacy DIspensIngs: 0 ML in 1 days Generated 08/102019 11:02 by Bureau of Prisons - NYM Par 2of 2 EFTA00059487 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 ce: 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 atehil Hypertiplderrda, unspecified Current HYPERTRIGLYCERIDEMIA Steep apnea Current Constipation, unspecified Current Low back pain Current Neuralgia and neuritis, unspecified Current No Diagnosis Current Injury, unspecified Current R/0 self inflicted injuries. Medical History as of Dental Health History Encounter date: 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 07/26/2019 07:54 Gorarated 07/26,2019 07:59 by DOS Bureau of Prisons • NYM Page 1 of 3 EFTA00059488 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01120/1953 Sex: Ivi Encounter Date: 07/26/2019 07:54 Provider alliaDDS Reg #: 7631 Facility: NYM 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: Chiamydla In 2015, treated Chicken pox in childhood Other Health Issues: Other Medical Conditions And Treatmont: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 Methamphotamine: No Tobacco products: No Other drugs: No Sensitive tooth: 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 07128/2019 07:59 by DDS Eturuau of Prison, • NYM Pan 2 of 3 EFTA00059489 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/26/2019 07:54 Provider. ADDS 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 da4 for 30 days Omega 3 (Vascopa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by north 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 TelephoneNerbal Order No Completed by DDS on 07/26/2019 07:59 Generated 07/26/2019 07:59 by DOS Bureau of Prison NYM p.o.3 of 3 EFTA00059490 Bureau of Prisons Health Services Dental A&O Exam Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #:. 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Encounter Date: 07/26/2019 07:47 Provider. DS Unit H01 Reviewed Health Status: Yes Occlusion: Class I Oral Hygiene: Fair CPITN: 3 2 1 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 Nen: Yes Dental A&O Screening Exam findings entered on EPSTEIN, JEFFREY EDWARD by S on 07/26/2019 07:47. Generated omenoie 08:00 by ODS Bureau of Prisons NYM papaldl EFTA00059491 Bureau of Prisons Health Services Dental Soap/Admin Encounter Inmate Name: EPSTEIN. JEFFREY EDWARD Reg ti: Date of Birth: 01/20/1953 Sex: Dental Facility: Encounter Date: 07/18/2019 13:48 Provider: Dental Asst Unit: 76318-054 NYM Z05 Screening encounter at Dental Clinic. Reason Not Done: Unavailable Comments: Patient has had several call outs for his Dental A & 0 screening but has not been escorted to Cosign Required: No Completed by Dental Asst on 07/19/2019 13:49. e dental clinic. Generated 07/19/201913:49 by Dental Bureau of Prisons • NYM Page 1 of 1 EFTA00059492 Federal Bureau of Prisons U.S. Medical Center for Federal Prisons 1900 W. Sunshine Street Springfield, MO 65807 417-874-1621 "' Sensitive But Unclassified "' Name EPSTEIN, JEFFREY Reg U 76318-054 DOB 01/20/1953 Sex M Facility MCC New Ycrk Order Un Provider MD Collected 07/09/2019 13:34 Received 07/10/2019 10:44 Reported 07/10/2019 14:46 LIS ID 188191004 CHEMISTRY Sodium Potassium Chloride CO2 BUN Creatinine eGFR (IDMS) 137 4.7 99 27 17 1.05 >60 GFR units measured as mL/min/1.73 m"2. If African American multiply by 1.210. A calculated GFR <BO suggests chronic kidney disease if found over a 3 month period. Calcium Glucose AST ALT Alkaline Phosphatase Blirubin, Total Total Protein Albumin Globulin Alb/Glob Ratio Anion Gap BUN/Creat Ratio Cholesterol Triglycerides Calculation cf LDL is not appropriate for samples with a triglyceride greater than 400 mg/dL. Therefore the LDL is not calculated. HDL Cholesterol L 31 40-60 mg/dL Choi/HDL Ratio H 6.9 0.0-4.0 H H H 9.8 102 57 62 64 1.1 7.3 4.4 2.9 1.50 10.2 16.1 216 413 137-148 3.5-5.0 99-114 22-30 7-22 0.66-1.25 8.5-10.9 70-110 11-55 11-66 41-133 0.2-1.3 6.0-8.2 3.6-5.1 2.0-3.7 1.00-2.30 9.0-19.0 5.0-30.0 <200 10-150 mmol/L mmoUL mmol/L mmoUL mg/dL mg/dL mg/dL mg/dL U/L U/L U/L mg/dL g/dL g/dL g/dL mg/dL mg/dL HEMATOLOGY WBC NRBC% RBC Hemoglobin Hematocrit MCV MCH MCHC RDW-CV Platelet L 7.6 0.0 5.42 15.6 47.8 88.2 28.8 32.6 12.8 338 4.3-11.1 4.46-5.78 13.6-17.6 40.2-51.4 82.5-96.5 27.1-34.9 33.0-37.0 12.0-14.0 130-374 KfuL 'NUL IL P9 g/dL K/uL FLAG LEGEND L=Low Lt=Low Critical H=l-figh H!=High Cntical A=Abnorrnal Al =Abno al Critical Page 1 of EFTA00059493 Federal Bureau of Prisons U.S. Medical Center for Federal Prisons 1900 W. Sunshine Street Springfield, MO 65807 417-874-1621 ••• Sensitive But LInctassilled Name EPSTEIN, JEFFREY Reg # 76318-054 DOB 01/20/1953 Sex M Facility MCC New York Order Un 5.47U Provider. MD HEMATOLOGY MPV Neutrophils % Therapeutic decision making should be based on absolute values, rather than percentages Lymphocytes % Monocytes % Eosinophils % Basophils % Immature Granulocytes % Neutrcphits # Lymphocytes # Monocytes # Eosinophits # Basophils # Immature Granulocytes 10.4 58.7 25.0 11.1 4.1 0.8 0.3 4.4 1.9 0.8 0.3 0.1 0.02 HEMOGLOBIN A1C Hemoglobin A1C 5.7 -6.4 Increased Risk > 6.4 Diabetes 6.3 Collected 07/09/2019 13:34 Received 07/1012019 10:44 Reported 07/10/2019 14:46 LIS ID 188191004 6.9-10.6 IL cto 0.0-5.0 1.9-6.7 K/uL 1.3-3.7 K/uL 0.3-1.1 K/uL 0.0-0.5 K/uL 0.0-0.1 K/u L 0.00-0.50 10"3/uL <5.7 SEROLOGY RPR Non-Reactive Results may be affected in patients with severely advanced immunosuppression. Non-Reactive FLAG LEGEND L=Low LI=Low Critical H=High H!=High Critical A=Abnorrnal Al =Abnormal Critical Page 2 or' 3 EFTA00059494 Federal Bureau of Prisons U.S. Medical Center for Federal Prisons 1900 W. Sunshine Street Springfield, MO 65807 417-874-1621 ***Sensitive But unclassified "' Name EPSTEIN, JEFFREY Reg # 76318-054 DOB 01/20/1953 Sex M Facility MCC New York Order Unit E06-547U Provider MD Collected 07/09/2019 13:34 Received 07/10/2019 10:44 Reported 07/10/2019 14:46 LIS ID 188191004 HIV HIV 1/2 Negative Screening test - Soo confirmatory tostIng for Reactive results Neaten FLAG LEGEND L=Low L!=Low Critical H=High HI=High Critical A=Abnormal Al =Abnormal Critical Page 3 of EFTA00059495 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: 07/10/2019 16:58 Provider. Lab Result Receive Facility: NYM CosIgnod bye MD on 07/14/2019 18:12. &IMAM of Prisons • NYM EFTA00059496 BP-S358.060 MEDICAL TREATMENT REFUSAL CDFRM SEP C6 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24.2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental CO Won, and release the Buroau of Prisons and Its employees from any and all liability for respecting and f• owing my expressed wishes and directions. MD 7-24-2019 Counseled by Date Signature Signature of Wane s Date a is Sign NYM -N EW YORK MCC Date EFTA00059497 1 2 3 4 5 8 7 8 9 10 11 12 13 14 — 15 18 32 31 30 29 28 27 2825 21 23 22 21 20 19- 18 17 0 BP-A0618 A&O DENTAL EXAMINATION JUN 18 (initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Occlusion: Oral Hygiene: Good Fair , 00, CPITN: 3 3 2- 9 Head & Nock / Soft Tissue: D. apt I F: ltd Classirmatlem CL, Pain Scale: Scale: /10 Dental Prostheses; at Intake: Yes Type. CP Age: Cent:Mon : ATI io Russicy, 1.0.--)g—r 0--• z24,W /C5 /Ilea Di:. SW /2- Ace) or Citi-011A5 Ci175d ul4 Intra-cral Photos Taken: Yes CD Radiographs Taken: (Document findings on MO encrounter) Yes 9 Instructed how to obtain urgent and non-urgent dental care Yes: 1 Noc Treatment Primites: None: Ncn-urgent non-urgent Urgent Referred to Sick Cat Radiographs authenzed: PM: Prophylarig authorized: Yes i No (Moroni valid 18 months from examinalion date) SW5: Panorex Pa t Name:, sh n, D —Ccici -Jty E Dentst : -1 7 ‘ 3 Isre Nutt.: I US-`} institution:/ MCC NEW YORK Date: 7- 24 9. Signature Block/Stamp: DDta PDF Ghlet uental r MCC New York Presorted by P640) Replaces SP-A0(IIS 01JUN 10 EFTA00059498 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318 Date of Birth: 01/20/1953 Sex: gadgg;,..VUITE Facility: NYM Encounter Date: 07/28/2019 20:25 Provider: Ell=1=1. 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 Mats ° My R hand still has pins and needles sometimes' No change in appearance from previous exam. Pain: No OBJECTIVE: Pulse: Data lime Rate Per Minuto Location Rhythm Provider 07/28/2019 20:28 81 RN Respirations: Date nun Rate Per Provider 07/28/2019 20:28 NYM 14 RN Blood Pressure: Date 21= Value Location Position Cuff Sin provider 07/28/2019 20:28 NYM 157/91 SaO2: Mita Time Value(%), 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 07/28/201920:30 by RN Bureau of Prisons- NYM Page 1 of 2 EFTA00059499 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg it 76318-054 Date of Birth: 01/20/1953 Sex: Facility: NYM Encounter Date: 07/28/2019 20:25 illiSTE Provider. RN Unit H01 Forow-up in 12-24 Hours Patient Education Topics: Pate Initiated f ormiti Handout/Topic 07/28/2019 Counseling Plan of Care Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Compieted by RN on 07/28/2019 20:30 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Sim Outcome Verbalizes Understanding Generated 07/2812019 20:30 by RN Eturciou of Prisms - NW/ Pan 2 d 2 EFTA00059500 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: Race: WHITE Encounter Date: 07/28/2019 20:25 Provider: IIMIEN RN Facility: NYM Cosigned by MD on 07/28/2019 20:50. Bureau of Prisons - NYM EFTA00059501 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg it: 76318.054 Date of Birth: 01/20/1953 Sex: larial iTE 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 dos Pain: No OBJECTIVE: Pulse: Bute Time RAW Per Minute Location Rhythm Provider 07/28/2019 06:57 82 Respirations: Pate ILnti Rate Per Minute Provider 07/28)2019 06:57 NYM 14 RN Blood Pressure: nate rime Value Location Position Cuff Size Provider 07/28/2019 06:57 NYM 138/80 SaO2: Data Time Valuef%). 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/Norrnocephalic No: Facial Asymmetry, Battle's Sign, Raccoon Eyes, Deformity Eyes General Yes: PERRLA, Extraocular Movements Intact Face General Yes: Symmetric Generated 07/28/2019 07:22 by RN Bureau or Prisons - NYM RN Peg.1 of 3 EFTA00059502 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: eP asWHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: RN Unit 1101 Exam: No: Ecchymosls, Numbness, Swelling, Periorbital Edema Neck General Yes: Abrasion(s) Pulmonary Observation/Inspection Yes: Within Normal Limits No: Respiratory Distress, Tachypnea, Hyperventilation Cardiovascular Observation Yes: Normal Rate Musculoskeletal Shoulder Yes: Full Range of Motion R, Symmetric R No: Swelling R, Inflammation R Humerus Yes: Within Normal Limits R Elbow Yes: Normal Exam R, Full Range of Motion R, Non-Tender on Palpation R Radius / Ulna Yes: Normal Exam R, Full Range of Motion R Wrist/Hand/Fingers Yes: Full Range of Motion R, Non-Tender on Palpation R, Swelling R No: Inflammation R, Ecchymosis R, Erythema R, Tenderness R, Laceration(s) R, Abrasion(a) Contusion(s) R ROS Comments Received inmate AAOX3 In no acute distress, speaking in full sentenced ambulating independently C/ Right ann 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 ecchyrnosis 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: Pate Initiated format Handout/Tonic 07/28/2019 Counseling Plan of Care Generated 07/28/2019 07:22 by RN Bureau of Prisons • NYM Outcome Verbalizes Understanding Page 2 of 3 EFTA00059503 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Bldh: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: SRN Unit: H01 Date Initiated Esimat Handout/Tonic Copay Required: No Cosign Required: Yes TelophoneNerbal 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. Provider outcome Generated 07128/2019 07:22 by RN Bureau or Prisons - NYM Pie 3 of 3 EFTA00059504 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg ft 76:', 18-054 Date of Birth: 01/20/1953 Sex: M Race: WhITE Encounter Date: 07/28/2019 06:51 Provider: RN Facility: NYM Cosigned bye MD on 07/2812019 20:51. Bureau of Prisons - NYM EFTA00059505 Copay Roquirod:No TelephoneNerbal Orden 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 Sex: NSW. 07/26/2019 08:57 Provider-. MD Reg #: Facility: Unit: 76318-054 NYM HO 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: Medication Docusato Sodium Capsule Indication: Constipation, unspecified Cosign Required: No MD on 07/26/2019 08:58 Order Date 07/26/2019 08:57 Gene-Med 0726/2019 0B:58 by MO atteau ol Prisons-NYM Prescriber Order TAKE ONE 10 MG CAP Orally - Two Times a Day x 180 day(s) Page 1 al I EFTA00059506 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Reg 76318.054 Date of Birth: 01/20/1953 Sex: i m iSa Unit: Failily: NYM Provider: MD Note Date: 07/24/2019 16:10 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: No Completed by Cosign Required: No 24/2019 16:12 Generated 07/2412019 16:12 by Bureau of Prisons NYM Page 1 of 1 EFTA00059507 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Nemo: EPSTEIN. JEFFREY EDWARD Reg 76318-054 Date of Birth: 01/20/1953 Sex: NYM Note Date: 07/24/2019 16:10 Provider: =NM= 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 Te lephoneNer ba I Order: Completed by Cosign Required: No 24/2019 16:12 Generated 07/24/2019 1612 by MD Bureau of Prisons - NYM Page 1 of 1 EFTA00059508 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 bat MD on 07/26/2019 08:58. SHOW Or em.NYM - EFTA00059509 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: i s ailla Facility: NYM Note Date: 07/24/2019 15:10 Provider: 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 07/202019 15:17 by MD Bureau of Prisons • NYM Pago 1 of 1 EFTA00059510 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 1$: 76318.054 Date of Birth: 01/20/1953 Sex: • 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: ME 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: Data Time Fahrenheit Celsius Location Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral a MLP Pulse: Data Ilmo Rate Per Minute Location Rhythm Provider 07/24/2019 13:12 83 Via Machine Regular INN MLP Blood Pressure: Data II= Value Location Position Cuff Size a 07/24/2019 13:12 NYM 132/89 Right Arm Sitting Adult-regular MIMI MLP SaO2: Rate Time Value(%) Al[ Provider 07/24/2919 13:12 NYM 96 Room Air 1.11 MLP Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Appears in Pain Fxam Comments Follow up evaluation done for inmate Epstein. He does not look in any pain or distress. He still has the erythema around his neck. Central part of this erythema has some abrasion. Patient do of any respiratory problem or distress. He still does not want to explain how the skin Injury on his neck 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: Genoraux107/24/2019 13:24 by ?ALP s not complaint gipped. he Bureau of NYM Page 1 of 2 EFTA00059511 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: WHITE Facility: NYM Encounter Date: 07124/2019 13:08 Provider: . MLP Unit 1101 Follow-up at Sick Call as Needed Patient Education Topics: Pate Initiated Format Handout/Topic 07/24/2019 Counseling Access to Care 07/24/2019 Counseling Preventive Health Copay Required:No Cosign Required: Yes TelephoneNerbal 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. Outcome Verbalizes Understanding Verbalizes Understanding Gcnorulod 07/24/2019 13:24 by MLP Eluroau of Prisons • NYM Piga 2 d 2 EFTA00059512 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 76318-054 Date of Birth: 01/20/1953 Sex: Race: WHITE Encounter Date: 07/24/2019 13:08 Provider: imm MLP Facility: NYM Cosigned with New Encounter Note by D on 07/24/2019 16:10. Bureau of Prisons • NYM EFTA00059513 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: 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: MM. MLP Date of Injury: 07/23/2019 01:27 Work Related: No Work Assignment: UNASSG Pain Location: Pain Scale: 0 Pain Qualities: Where Did Injury Happen (Bo 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 Date Reported for Treatment: 07/23/2019 08:25 OBJECTIVE: Temperature: Date fine Fahrenheit Celsius Location 07/23/2019 06:30 NYM 97.5 36.4 Oral Provider EMI MLP Pulse: Pete Tune Rate Per Minute Location Rhythm provider 07/23/2019 06:30 92 Via Machine Regular . MLP Respirations: Pitt Time Rate Per Minute Provider 07/23/2019 06:30 NYM 16 . MLP Blood Pressure: Data. Tina Vailll Location Position Cuff Size Erraid_er 07/23/2019 06:30 NYM 140/85 Right Arm Sitting Adult-regular . MLP SaO2: Data Time Value(%) Air 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 07/23/2019 09.05 by MLP Bureau of Prisons • NYM Page 1 of 2 EFTA00059514 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: lair WHITE Facility: NYM Encounter Date: 07/23/201906:20 Provider. MLP Unit: H01 Exam: Acutely III Pulmonary Auscultation Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally No: Crackles, Rhonchi, Wheezing Fxam Comments Inmate for injury report as requested by Operational Lt. He is ambulatory, oriented x 3. In not apparent distress, smiling during this 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 inch 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 dlameler(mild). As per Information from custody staff inmate Epstein was found in his cell with a rope around his neck a sitting on the floor. Inmate is currently placed on suicide watch. ASSESSMENT: Injury, unspecified, T1490 - Current - R/O self Mflicted injuries. PLAN: Disposition: Folow-up at Sick Call as Needed Placed on Suicide Watch Fellow-up in 2-4 Hours Other: For follow up with psychology service. Patient Education Topics: naltunitlatad Emma Handout/Topic flia• 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 TelephoneNerbal Order: No Comp!eted by MLP on 07/23/2019 09:05 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Genurate0 07/23/2019 09:05 by MU' Bureau of Prisons • NYM Page2o1 2 EFTA00059515 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg tt: 76318-054 Date of Birth: 01/20/1953 Sex: Race: WHITE Encounter Date: 07/23/2019 06:20 Provider. MIMI MLP Facility: NYM Cosigned by 1D on 07/2312019 15:44. Bureau diMars NYM EFTA00059516 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07114/2019 17:36 Sex: Provider: Reg 1$: 76318 M Race: WHITE Facility: NYM MD Unit: Z05 54 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 TRI L WAS 800 , NOW 431. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERID MEDS DUE TO THEIR GI SIDE EFFECTS. HX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CP MACHINE. STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTE STATES THE FBI LOKELY HAS L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES. SURGICAL HX: NONE MENTAL HEALTH HX: NONE Pain: Yes Pain Assessment Dato: 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: Reason Not Done: Comments: MEDROL DOSE PACK Soon for clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid Added to clinIc(s): OrthopecIldRheumatology, 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 Mn Bureau of Prisons • NYM Page 1d 3 EFTA00059517 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sox: M Race: WHITE Facility: NYM Encounter Date: 07/14/2019 17:36 Provider: MD 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 S1 and S2 No: MIRJG Abdomen Auscultation Yes: Norma-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: Siff Medication Order Date Omega 3 ( Vascepa) 1 GM Capsule 07/14/2019 17:36 Indication: Hyperlipidemia, unspecified New Laboratory Requests: Retails Frequen Lab Tests-H-Hemoglobin A1C One Time Lab Tests-L-Lipid Profile Additional Information: Genera:ad 07/14/2019 18:11 by MO Buroau of Pelson NYM Rue Pate 10/10/2019 00:00 Routine Prescriber Order TAKE 2 CAPS (cagy - Two Times a Day x 1 dey(s)— TAKE WITH FO . P696242( 3 EFTA00059518 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg N: 76318-0fr4 Date of Birth: 01/20/1953 Sex: E Facility: NYM Encounter Date: 07/14/2019 17:36 Provider: MD Unit: Z05 ' FASTING. Lab Tests-H-Hep B surface Ab Lab Tests-H-Hep B surface Ag Lab Tests-H-Hep C Ab Lab Tests-H-Hepatic Profile Schedule: One Time 08/08/2019 00:00 Routine Activity Date Scheduled, Scheduled Provider Clinical Encounter 07/24/2019 00:00 Optometrist 66 YR OLD MALE FOR ROUTINE SCREENING. Chronic Care Visit 01/07/2020 00:00 Mid-Level Provider 6 MONTH F/U. Chronic Care Visit 07/01/2020 00:00 Physician 01 Other: PENDING EKG AND FOBT. CXR WAS REFUSED. Patient Education Topics: Date Initiated formal flardougTopig 07/14/2019 Counseling Diagnosis Copay Required:No TeiephoneNerbal Order: No Completed by Cosign Required: No MD on 07/14/2019 18:11 provider Beaudouin, Robe 1211101111 Verbalizes Understanding Generated 07/1O2019 1811 by MD Bureau of Prisons - NYM P0003013 EFTA00059519 BP-S358.060 MEDICAL TREATMENT REFUSAL SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS CDFRM 7-24-2019 Date I JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Fe eral Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. MD 7-24-2019 Counseled by Date Si nature of Wane s Date NYM—NEW YORK MCC EFTA00059520 BP-S358.C60 MEDICAL TREATMENT REFUSAL COMM SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-10-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condltion(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: 66 YR OLD MALE WITH NO PMI-IX , REFERRED FOR ROUITNE CXR. The following treatment(s) was/were recommended: CHEST X-RAY • Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: WORSENING THE CONDITION IF THERE IS ANY FINDINGS • • I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. X-RAY 7-10-2019 Counseled by . Date Signature of Witness NYM-NEW YORK MCC EFTA00059521 BP-5358.060 SEP OS U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS MEDICAL TREATMENT REFUSAL CDFI1M 7-24-2016 Date I, JEFFREY EPSTEIN 76318.054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the folio ving possible consequences and/or complications may result because of my refusal to accept trea ment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and f llowing my expressed wishes and directions. MD 7-24-2019 Counseled by Date Pa nt's Sign i Date alter Si nature of VVitne s l Date Sr NYM--NEW YORK MCC EFTA00059522 BP-A0618 JUN 16 U.S. DEPARTMENT OF JUSTICE A&O DENTAL EXAMINATION (Initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS 1 2 3 4 5 8 7 8 9 1011 1213 14. 15 16 O 32 31 30 29 28 27 26 25 24 23 22 21 20 19 - 18 • I? 4 It Occlusion: Oral Hygiene: Good Fe CP;TN: 3 2 3 3 2- 3 Mead & Neck / Soft Titarrre D; Classification: CLIC. Pain Scale: Dental Prostheses at Intake: Yes No Typo: Ase: Condition: Conlin 40 CC.Ci2 SS, 14" --.1e C"'"- i Ci eotl 4tV411 , in nica on Di, Seili-e- Ael at CarzysliAc 0.109-P-14 Infra-oral Photos Taken Radiographs Taken: (Document findings cn A&O encounter) Yes Yes 0 No • Instructed hcnv to obtan urgent and non-urgent dental care: Yes: I No: Treatment Priorities: None: Non-urgent non-urgent Urgent Refierred to Sick Cat Radiographs authorized; Prophylaxis authorized: Yes I No PM: (Approval va-xl 18 months from examination date) BWs I Panorex Pap nt Name: s- 1 -3--e_c-R•fe can Den DDSs .,:krEte Number: i Institution: / Date: signature Blar.k/Stamp: 7 4,3 is: os-1/41 MCC NEW YORK 7-* 2-6 —/ 9. IDS. PDF Prescribed by P6403 et en cer MCC New York Replaces BP-A0B18 olJUN 10 EFTA00059523 BP4,0618 JUN 18 U.S. DEPARTMENT OF JUSTICE A&O DENTAL EXAMINATION (Initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS Ocduslon: ■ 1 2 3 4 6 8 7 $ 0 1011 12 13 14 15 18 t9 32 31 30 29 25 27 2825 21 23 22 21 20 10. 18 17 (AL fy Nt I F: Li Pain Scale: Oral Hygiene: Good CPITN: 3 2- 3 Head & Neck Soft Tissue: Cla ificatLOn: CL- -T- /10 Dental Prostheses et Intake: Yes No Typo: Age: Codition: Crcrirnrantl 4O it 02 SS / 1.4 -r C,...-‘,Aci Z it (tercV ' N2511•14, 1 SeiV-e- on C4r) inc 0 o/ Cityyld. .19Se-file4 Infra-oral Photos Taken: Yes 0 Radiographs Taken: (Document findings on AM) encounter) Yes 9 . Instructed how to cbtaLn urgent and non-urgent dental care: Yes: I No: Treatment PrioriSes: None: Nen-urgent non-urgent Urgent Referred to Sick Cail: Radiographs PM: BWs Panore:c authorized: • Prophylaxis authortzed: Yes I No (Approval valid 10 months from examination date) Palient Narrar. , C,..-isti r skin , -3-cc-R--e_v £ D " nature: I>Ds ELI- -76 r Hanby: 3 I Se:- os-m Institution: / MCC NEW YORK Date: 7- 26 -1 9. Signature Block/Stamp: 9 DS PCF Presented by P8400 et en a ter MCC New York Replaces BP-A0618 of-UN 10 EFTA00059524 SP-S358.060 MEDICAL TREATMENT REFUSAL COFFIM SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Fe eral Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental co dition, and release the Bureau of Prisons and its employees from any and all liability for respecting and f (lowing my expressed wishes and directions. MD 7-24-2019 Counseled by Dale Si nature of VVitne Dale NYM-NEW YORK MCC Date EFTA00059525 Federal Bureau of Prisons U.S. Medical Center for Federal Prisons 1900 W. Sunshine Street Springfield, MO 65807 417-874-1621 ••• Sensitive But Unclassified"' Name EPSTEIN, JEFFREY Reg # 76318-054 DOB 01/20/1953 Sex M Facility MCC New York Order Unit E06-547U Provider WI= MD Collected 07/09/2019 13:34 Received 07/10/2019 10:44 Reported 07/10/2019 14:46 LIS ID 188191004 HIV HIV 1/2 Negative Screening test - See confirmatory teeing (or Reactive results Negative FLAG LEGEND L=Low LI=Low Critical H=High HI=High Critical A=Abnormal Al =Abnormal Critical Page 3 of 3 EFTA00059526 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76118-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/10/2019 16:58 Provider: Lab Result Receive Facility: NYM Cosigned by MD on 07/14/2019 18:12. Bureau of Prisons - NYM EFTA00059527 BP-S358.C,50 SEP 05 MEDICAL TREATMENT REFUSAL CDFRM U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that tho following possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. MD 7-242019 Counseled by Date ark ~ i SI nature of VVitne s Date NYM—NEW YORK MCC Date EFTA00059528 SP-A0618 JUN 18 U.S. DEPARTMENT OF JUSTICE A&O DENTAL EXAMINATION (Initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS Occlusion: • 1 2 3 4 6 6 7 8 9 1011 1213 14. 15 IC 2 32 31 30 29 23 27 2625 2123 22 21 20 W. 18 17 CC It* Oral Hygiene: Good Fair I/ OOr Craw: 3 . 3 3 2- 9 Head 8 Neck / Soft Tissue: D: rgt F: Classification: CL_ en- Pain Scale: /1G Dental Pros-theses at Mai= Yes TYPo: Age: Condition: Cp s: Ina/ ...67 cccession / a -1° c C. a ii,15 aka Di, Seil.) -12- --s. i tel ed- Cco-OcLiA5 0 109-/484 Intra-cind Photos Taken: Yes 0 Radiographs Taken: (Document frndings on A&O encounter) Yes No Instructed how to obtain urgent and non-urgent dental care: Yes: I No: Treatment Pitontes: None: Non-urgent non-urgent Urgent Referred to Sick Call: Radiographs authorized: PAs• . Prophylaxis auUtortzect Yes I No (Approval var 18 months from examination date) EPNs: Panorox iPc t Nan= i 9 4t, n -376 1-rite_ E. Dentist Si nature: 1,3" it 7‘ lisznben 3 IS= OS-1/4\ Institution: MCC NEW YORK Date: 7- 06 -1 9. Signature Block/Stamp: DDS. PDF Peescrtbed by P8400 eniet IJenta101ticer MCC New York MOWN 8P-Men NUN 10 EFTA00059529 SEP 05 SP-S358.060 MEDICAL TREATMENT REFUSAL C0FRM U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and • wing my expressed wishes and directions. MD 7-24-2019 Counseled by Dale Si nature of Wan s Date a is Sig NYM-NEW YORK MCC 1 EFTA00059530 BP-S358.CE0 MEDICAL TREATMENT REFUSAL CDFRM SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-10-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: 66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR. The following treatments) was/were recommended: CHEST X-RAY Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: WORSENING THE CONDITION IF THERE IS ANY FINDINGS I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and Its employees from any and all liability for respecting and following my expressed wishes and directions. X-RAY 7-10-2019 Counseled by Date Signature of Witness Date Patten Signature t Date NYM—NEW YORK MCC EFTA00059531 SP-A0618 A&O DENTAL EXAMINATION JUN 18 U.S. DEPARTMENT OF JUSTICE • • • (Initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS Occlusion: 1 2 3 4 5 8 7 8 0 1011 1213 14. 15 16 (2 32 31 30 29 28 27 2825 2423 22 21 20 18. 18 17 21 r 11A Oral Hygiene: Good Fair Zoo r CPITht 3 3 3 2- 3 Head & Neck / Soft Tissue: O: C 7 lv P L I ClassL5cation: CL_rr Pain Scale: /10. Dental Prostheses at Intake: Yes No Type: fi e" Calditicn: Comml .k rim r-toz SS / 14.., 0 -0-- O---‘, cet On 017Sal• Le^ ni )r_15,1Ai • or C/o-OAJA1 plosefik-4 InUa-oral Photos Taken: Yes 0 Radiographs Taken: (Document findings on ASO encounter) Yes No . I Instructed hcriv to ahem' urgent and non-ergent dental care: Yes: I No: Treatment Haan: None: Nco-tegent non-urgent Urgent Referred to Sick Cat Radiographs authorized; PAs: . - Prophylaxis authorized Yes i No (Approval valid 18 months from examination date) BW5: Pan Pa Name: Pa 'ca —C; n 1 trcc-civey E. Dentist SI lure: 1>Ds Nurnbec , 4? S '7C 3 IC= OS1/4\ institution: t MCC NEW YORK Date: 7— 7 6 --/ 9 • Ignature Slock/StamP: DS. PDF Presaibed by P8400 te entl lcer MCC New York • Replaces BP•Atal 8 of JUN 10 EFTA00059532 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 08/10/2019 07:25 Sex: M Race: WHITE Provider. Reg #: 76318-0 Facility: NYM RN Unit: Z04 Emergency Code - Resuscitation Event encounter performed at Special Housing Unit. SUBJECTIVE: Emergency Note Provider: RN Team Members: Provider Balt RN Team/Code Leader Code Events: 1-Yea CPR Value, Compressions EKG/Monitor Lifepak No shock advised CPR Compressions Oxygen 15 L IV Access Peripheral IV 18 g Left AC Airway Endotracheal Tube ET Tube 7.5 24CM to L Lip line Placed by Paramedics Medications Epinephrine 1mg IV Epinephrine 3 doses and Sodium bicarb 2 doses administered CPR Compressions Medications Sodium Bicarbonate 1 mEa/kg IV IV Fluids Normal Saline 0.9% 1000 ml Medications Epinephrine 1mg IV CPR Compressions Medications Sodium Bicarbonate 1 mEa/kg IV Medications Epinephrine 1mg IV CPR Compressions Comments: Date 08/10/2019 06:35 08/10/2019 06:39 08/10/2019 06:40 08/10/2019 06:47 08/10/2019 06:48 08/10/2019 07:08 08/10/2019 07:10 by paramedics 08/10/2019 07:11 08/10/2019 07:11 08/10/2019 07:12 08/10/2019 07:13 08/10/2019 07:14 08/10/2019 07:14 08/10/2019 07:16 08/10/2019 07:17 Responded to a body alarm at 0635 for medical emergency on 9S, Upon arrival Inmate was received o the floor of his cell unresponsive with CPR in progress by correctional officers, Inmate was Cold, with circumferential B ising around the neck and posterior mottling, Pupils Fixed and dilated, No Palpable pulses. Call place for EMS, CPR timed, AED Placed No shock advised, CPR Continued, inmate transported to HSU treatment room with CPR in pro ress, 18g hep lock to L AC, O2 15 Lt ViA BVM, Pulse Check NO SHOCK advised. EMS and Paramedics arrived 0656, Pla ed 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 69110/2019 08:10 by RN Bureau of Prisons - NYM Pap 1 of 2 EFTA00059533 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: ISSIII ITE Facility: NYM Encounter Date: 08110/2019 07:25 Provider: RN Unit: Z04 Exam: ASSESSMENT: Cardiac Arrest PLAN: New Consultation Requests: Consultation/Procedure Emergency Room 08/10/2019 08/10/2019 Emergent Subtype: AMBULANCE Reason for Request: Cardiac arrest with CPR in progress Copay Required:No Cosign Required: Yes TelophoneNerbal Order: No Completed b RN on 08/10/2019 08:10 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. larRethate Scheduled Target Date Priority Translator Language No Generated 08110/2018 08:10 by RN Bureau of Prisons - NYM Pepe 2 of 2 EFTA00059534 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Facility: NYM Encounter Date: 07/30/2019 15:58 Provider. der Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: AD 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 MAC INE. I INFORME DHIM THAT WE RECEIVED HIS CPAP MACHINE AND IT WILL BE GIVE TO HIM TONIGHT.. HE REPORT OTHER NON-MEDICAL ISSUES. STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Seen far clinic(s): Pulmonary/Respiratory, Orthopedlc/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 Si and S2 No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neurologic Generated 07130/2019 16:12 a MD Bwoau of Prisons • NYM Poop 1 of 2 EFTA00059535 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 ZO1 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, 26827 - Current Constipation, unspecified, K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hypedipidemia, 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: Ert! Medication INsulin REG - Human Indication: Prediabetes Discontinued Medication Orders: Medication 122148-NYM Insulin Rog (10 ML) 100 UNITS/ML In] Order Data 07/30/2019 15:58 Order Date 07/30/2019 15:58 Discontinue Type: When Pharmacy Processes Discontinue Reason:new artier written Indication: Copay Required: No TelephoneNerbal 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 subcuteneousisi per sliding scale: twice daily "VT line*" for 7 days Generated 07/30/2019 16:12 by MD Bureau cr Prisons • NYM Pegs 2 2 EFTA00059536 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg ll: 76318-054 Date of Birth: 01/20/1953 Sex: TE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: tvID Unit: 201 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT S REFERRED BY THE WARDEN FOR EVALUATION. PATIEN E RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO E RRR S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STAT BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. HE DENT ,6 SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING AL. OWING. HE REPORTST qp3, IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. HE REPORTS H NEY STONES. HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEW5f AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HEREt§ CE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE R Et D HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-ME STATES HE FEELS OTHERWISE Pain: Not Applicable UES. MD Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology. OBJECTIVE: Pulse: nate 07/30/2019 07/30/2019 07/30/2019 Respirations: Time Rate Per Minute 13:02 94 09:40 88 09:30 87 Location Respiratory Provider MD Via Machine MD Via Machine Date Time Rate Per Minute Provider 07/30/2019 09:30 NYM 12 Blood Pressure: Date Time Value Location 07/30/2019 13:02 NYM 114/84 Loft Arm 07/30/2019 09:40 NYM 125/60 Right Arm 07/30/2019 09:30 NYM 108/86 Loft Arm SaO2: aat Time Valuef%1 Air Provider 07/30/2019 09:30 NYM 98 Room Air MD Weight: 2119 Time LL s gs Waist Circum. Provider • osition Standing Standing Sitting MD Cuff Size Ov' St I MD MD MD Generated 07/3012019 14;05 by MD Bureau of Prisons • NYM Page 1 of 3 EFTA00059537 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg ri: 76318.054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: MD Unit: Z01 Date Time 07/30/2019 09:30 NYM 194.2 88.1 MD Lla Kg Waist circum Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distre ed. Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic. Disheveled, Unke Acutely III Nutrition No: Appears O Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR 1 and S2 No: M/R/G Musculoskeletal Tibia / Fibula Neurologic No: Edema 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: Rx Medication Order Date prescriber Order Generated 07/30/2019 14:05 by MO Bureau of Prisons • NYM Page 2 of 3 EFTA00059538 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 11:12 Provider: TE t MD Now Medication Orders: 8,31 Medication Order Date Magnesium Hydroxide Susp cone 800 07/30/2019 11:12 MG/5ML Indication: Constipation. unspecified INsulin REG - Human 07/30/2019 11:12 Indication: Prediabeles Renew Medication Orders: Exit Medication. Order Date 07/30/2019 121836-NYM methylPRD o ne 4 MG Tab ( 21 count 11:12 Pack) Indication: NJ Thia and neuritis, unspecified New Laboratory Requests: Details Frequency Lab Tests - Short List-General-CBC w/diff no Time 08/01/201900:00 Routine Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short List-General•Comprehonsiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic New Radiology Request Orders: Details Reg It: 76318.054 Facility: NYM Unit: 201 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 Priority. Frequency, Due Date Priority. General Radiology-Spine / Cervical- One Time 08/29/2019 Routine General Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI PLEASE PERFORM C SPINE SERIES Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiaten Format 07/30/2019 Counseling 07/30/2019 Counseling Copay Required:No TelephoneNerbal Order: No Completed by - R 2-3 MINUTES 3 DAYS AGO. Handout/Tot& PrQvider Access to Care Beaudo Plan of Care Cosign Required: No MD on 07/30/2019 14:05 Clu_tcocae Verbalizes Understanding Verbalizes Understanding Generated 07/30/2019 14:05 by MD Bureau of Prisons • NYM Page 301 3 EFTA00059539 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/30/2019 11:12 Sex: Provider: MD Reg #: 76318.054 Facility: NYM Unit: ZO1 Chronic Care - Chronic Care Clinic encounter performed al Health Services. SUBJECTIVE: COMPLAINT 1 Provider: MD Chief Complaint: Other Problem Subjective: PATIENT AS REFERRED BY THE WARDEN FOR EVALUATION. s e PATIEN rigEP,ORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO AE 11:InTS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STATES) HE DENI SPEAKING HE REPORT HE REPORTS H TOPROL. HE AHS A HX OF SLEE_P_Ap AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HER CE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE R Et1LED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-ME UES. STATES HE FEELS OTHERWISE Pain: Not Applicable BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. SIDED WEAKNESS, DIPLOPIA. FACIAL DROOP, DIFFICULTY ALLOWING. IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. DNEY STONES. FIX OF HTN FOR WHICH HE WAS TAKING Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rhoumatology, OBJECTIVE: Pulse: 7) Dag 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 07/30/2019 Blood Pressure: Time 09:30 NYM espiratory Rate Per Minute. Provider 12 MD 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 Silting SaO2: Qata nom 07/30/2019 09:30 NYM Weight: Rate Time Provider MD MD MD Cuff Size Provider Beaudouin. Robert MD MD Beaudouin. Robert MD Value170). A.it Provider 98 Room Air Lk Ka Waist cirsam Provisisi MD Generated 07/30/2019 14:05 by MD Bureau of Prisons • NYM Page 1 of 3 EFTA00059540 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg ti: 76318.054 Date of Birth: 01/20/1953 Sex: l i aise Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: MD Unit: Z01 !Tats Time .K.9 07/30/2019 09:30 NYM 194.2 88.1 Exam: General Affect Waist Circum Provider MD Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distre ed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unke cutely III Nutrition No: Appears Ott Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neu rolog lc Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: viz?1 ,11 le5and S2 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, 64730 - Current PLAN: New Medication Orders: Medication Order Date Proscriber Order Generated 07130/2019 14:05 by MD Bureau of Prisons - NYM Page 2 or 3 EFTA00059541 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 76318.054 Date of Birth: 01/20/1953 Sex: is... Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: MD Unit: Z01 Now Medication Orders: !WI NI • dication Order Date Prescriber Order Magnesium Hydroxide Susp cone 800 07/30/2019 11:12 10 CC Orally - Two Times a MG/5ML Day PRN x 90 day(s) Indication: Constipation, unspecified INsulin REG - Human 07/30/2019 11:12 SLIDING SCALE Subcutaneously - Two Times a Day x 7 day(s) Pill Line Only Indication: Prediabetes Renew Medication Orders: Exit Medication Order Dale, Prescriber Order 121836-NYM methylPR o ne 4 MG Tab ( 21 count 07/30/2019 11:12 Take the tablet by mouth as Pack) directed x 6 day(s) Indication: iTh 1tt, is and neuritis, unspecified New Laboratory Requests: Details V Frequency Due Date Priority Lab Tests - Short List-General-CBC w diff Time 08/01/2019 00:00 Routine Lab Tests-P-PSA, Total Lab Tests-U-Uric Add Lab Tests - Short List-General-Comprehensiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic New Radiology Request Orders: Details Frequency Due Date Priority General Radiology-Spine / Cervical- One Time 08/29/2019 Routine General Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI R 2-3 MINUTES 3 DAYS AGO. PLEASE PERFORM C SPINE SERIES Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format 07/30/2019 Counseling Handout/Topic Access to Care 07/30/2019 Counseling Plan of Care Copay Required:No Cosign Required: No TelephoneNerbal Order: No Completed by MD on 07/30/2019 14:05 vidir atitcomq Verbalizes Understanding Verbalizes Understanding Generated 07/30/2019 14:05 by MO Bureau of Prisons • NYM Page 3 of 3 EFTA00059542 Bureau of Prisons Health Services See Amendment Irmate 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 noto by MD on 07/30/2019 16:12. Bun= of Prisons - NYM EFTA00059543