EFTA00110337.pdf

BP-S358.060 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 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 5X re 5 tions. 7-24-2019 unse Date NYM-NEW YORK MCC EFTA00110337 BP-S358.C60 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 treatment(s)waslwere recommended: CHEST X-RAY Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: WORSENING THE CONDITION IF THERE IS ANY FINDINGS I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical andlor 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 Patien Signature Date 1 11 Wilii - ( 0 ( gna ure o Mess Date NYM-NEWYORK MCC EFTA00110338 I I I. BP-5358.060 MEDICAL TREATMENT REFUSAL CDFRM SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I, JEFFREY EPSTEIN 76318-054 refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse 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 Dale Pa nes Sign r Date NYM--NEW YORK MCC EFTA00110339 BF-A0618 JUN 16 U.S. DEPARTMENT OF JUSTICE A&O DENTAL EXAMINATION (Initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS Occlusion: • AA 1 2 1 4 5 6 7 8 9 1011 1213 14 15 18 Fri O 32 31 30 2D 28 27 2825 24 23 22 21 20 19 • 18 17 21 CC mmomel;;' Oral Hygiene: Good Fair , oar CP:TN: 3 3 3 3 Head 8 Neck / Soft Tissue: D: M: I F: Classification: CL Pain Scale: /10 Dental Prostheses at intake: es No Type: Age: Contrition: ComnAl Ii7 aO r Irjt , ri V )72.5 i Vet" r-ccess. cy-) ekt Sen) -e- OL-7e-e- 0--Niell or Citr-s.SAJA c O.105re-M41 Intra-oral Photos Taken: Yes 0 Radiographs Taken: (Document findings on A8O encounter) Yes 9 • Instructed how to obtain urgent and non-urgent dental care: Yes: 1 No: Treatment Priorities: None: Non-urgent non-urgent Urgent Referred to Sick Cali: Radiographs authorized: PM: Prophylatis authorize& Yes i No (Approval valid 18 months from examination date) BWs: Perron= frit Name: Skin i i -O—e_Fici--e_ty S Den' Signature Block/Stamp: DOS. ..km f- Number. --7(, 3 lc= Us-Li institution: / MCC NEW YORK Date: 7- 26 -/ 9. PDF Presaibed by P6400 let uentatofficer MCC New York Replaces BP-A0618 of JUN 10 EFTA00110340 I 1 2 3 4 5 0 7 8 0 1011 1213 14 15 16 m r- 0 32 31 30 2D 28 27 26 25 24 23 22 21 20 10 18 17 BP-A0618 JUN 18 U.S. DEPARTMENT OF JUSTICE A&O DENTAL EXAMINATION (initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS Occlusion: Oral Hygiene: Good Fair Poor CPFIN: 3 2- 3 3 2 — Head & Neck / Soft Tissue: D rt I F: Classification: CL_ Pain Scale: /10. Dental Prostheses at Intake: Yes No Type: Ae: Condition: Comzrt _to z it t bettv r i i ..g),:iiilitca R Ce SS / OO DICX Sen.)-e- a Lot-Act 0--4,4 pc Ce-O-1,O-ini ojoScAle4 Intra-oral Photos Taken: . Yes 0 Radiographs Taken: (Document findings on A&O encounter) yes O • Instructed how to obtain urgent and non-urgent dental care: Yes: I No: Treatrnent Priorities: None: Non-urgent non-urgent Urgent Referred to Sick Can: Radiographs authorized: PM: - Prophybcds 811 (Approval vaad 18 i No date) k Yes months from examination BWs: Panorer Patient Name: ,,-- $4Q n i -3 -e_c Thy E Dent; • -1 9. sir . ft , r Number 76 3 iSC OS-LI Institution: / MCC NEW YORK Date: 7— 24, Signature Block/Stamp: DDS. PDF Prescribed by P6400 Chief Dental Officer MCC New York Replaces BP-A0618 of vUN 10 EFTA00110341 OP-5358.060 MEDICAL TREATMENT REFUSAL COFRM SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I, JEFFREY EPSTEIN 76318-054 refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse 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 Pa nt's Sign NYM-NEW YORK MCC Dale EFTA00110342 Federal Bureau of Prisons U.S. Medi **' 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 I HIV HIV 1/2 Negative Screening test - See confirmatory testing for Reactive results Negative FLAG LEGEND L=Low LI=Low Critical H=High H!=High Critical A=Abnormal A! =Abnormal Critical Page 3 of 3 EFTA00110343 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 Cosigned by MD on 07/14/201918:12. Bureau of Prisons - NYM EFTA00110344 BP-5358.C60 MEDICAL TREATMENT REFUSAL CDFRM SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse 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. D 7-24-2019 Counseled by Date Pa nts Sign Date it 1. t NYM--NEW YORK MCC EFTA00110345 BP-A0618 A&O DENTAL EXAMINATION JUN 16 (Initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS • 2 3 4 5 8 7 B 9 1011 1213 14 15 16 2 32 31 30 29 28 27 28 25 24 23 22 21 20 19 • 18 17 CC '.4!1fl!Ir't tit It Occlusion: Oral Hygiene: Good Far / Oct CPITfit. 3 3 3 2- 3 Head & Neck/Soft Tissue: D: M: F: Classification: CLer Pain Scan: /10 Dental Prostheses at Intako: Yes No Type: Age: Condlion: Cowl ek RCe SS / LoLjta - C,..-s...ko..4 = et in 1 vca De) CIPSen.)-e- • or Cal-Oa:MS 0.105refil 4 Intra-oral Photos Taken: Yes 0 Radiographs Taken: (Document findings on MO encounter) Yes No • Instructed how to obtain urgent and non-urgent dental care: Yes: i No: Treatment Priorities: None: Non-urgent non-urgent Urgent Referred to Sick Call: Ftadlographs authorized; PM: Prophylaxis authorized: Yes I No (Approval valid 18 months from examination date) BWs: Panorex-. Pa' ant Nam a n i --) .61P-9._ v S Denhs 1) 1)-5 ..4.4 N&i k nber 76 3 I Sr- USN Institution: / MCC NEW YORK Date: Signature Block/Stamp: -7- zOi --1 9. IIIIMDDS. PDF Presaibed by P64C0 let en a icer MCC New York RepNces BP-A0618 of JUN 10 EFTA00110346 SP-S358.060 MEDICAL TREATMENT REFUSAL SEP 05 COFRM 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 following my expressed wishes and directions. D 7-24-2019 Counseled by Date NYM-NEW YORK MCC EFTA00110347 BP-S358.060 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 PIVIHX , 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 tho 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 Patient Signature Signature of Witness Date NYM-NEW YORK MCC Date EFTA00110348 E3P-A0618 JUN 16 U.S. DEPARTMENT OF JUSTICE A&O DENTAL EXAMINATION (Initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS • NM X - 1 2 3 4 5 8 7 8 9 1011 1213 14 15 16 WI L9 32 31 30 20 28 27 2625 2423 22 21 20 10 18 17 Occlusion: Oral Hygiene: Good Fair Poor CPITN: 3 z 3 2- 2 Head & Neck! Soft Tissue: D: M: F: Classification: CL? Pain Sonic: /1G Dental Prostheses at Intake: Yes No Type: Age: Condition: Comin 4 2 tel it (12 SS i Za...,ter 0....N. skol 120.- on Di, 17.25 I IA a Seru-e. • or Congini 0.1054/4 4 Intra-cral Photos Taken: Yes 0 Radiographs Taken: (Document findings on A&O encounter) Yes 9 • Instructed how to obtain urgent and non-urgent dental care: Yes: I No: Treatment Priorities: None: Non-urgent non-urgent Urgent Referred to Sick Cal. Radiographs authorized: PM: • Prophylaxis authorized: Yes I No (Approval vaFrl 18 months from examination date) BWs: Panormc Pent Name: i 4sti Denblil t --1 9 . bps n , --)c-C-Vizy E Number. / 4 -n, 3 IQ: ()Sy MCC Institution: / NEW YORK Date: 7-2-6 Signature Block/Stamp: DDS. PDF Prescribed by P6403 Chief Dental Officer MCC New York Replaces BP-A0618 of JUN10 EFTA00110349 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 08/1012019 07:25 Provider: RN Unit: Z04 Emergency Code - Resuscitation Event encounter performed at Special Housing Unit. SUBJECTIVE: Emergency Note Provider: RN Team Members: Provider Ha& RN Team/Code Leader Code Events: Tvoe Value Date CPR Compressions 08/10/2019 06:35 EKG/Monitor Lifepak 08/10/201906:39 No shock advised CPR Compressions 08/10/2019 06:40 Oxygen 15L 08/10/201906:47 IV Access Peripheral IV 08/10/2019 06:48 18g Left AC Airway Endotracheal Tube 08/10/2019 07:08 ET Tube 7.5 24CM to L Lip line Placed by Paramedics Medications Epinephrine 1mg IV 08/10/201907:10 Epinephrine 3 doses and Sodium bicarb 2 doses administered by paramedics CPR Compressions 08/10/2019 07:11 Medications Sodium Bicarbonate 1 mEa/kg IV 08/10/2019 07:11 IV Fluids Normal Saline 0.9% 1000 ml 08/10/2019 07:12 Medications Epinephrine 1mg IV 08/10/2019 07:13 CPR Compressions 08/10/2019 07:14 Medications Sodium Bicarbonate 1 mEa/kg IV 08/10/2019 07:14 Medications Epinephrine 1mg IV 08/10/2019 07:16 CPR Compressions 08/10/2019 07:17 Comments: Responded to a body alarm at 0635 for medical emergency on 9S, Upon arrival Inmate was received on the floor of his cell unresponsive with CPR in progress by correctional officers, Inmate was Cold, with circumferential Bruising around the neck and posterior mottling, Pupils Fixed and dilated. No Palpable pulses, Call place for EMS, CPR Continued, AED Placed No shock advised, CPR Continued, inmate transported to HSU treatment room with CPR in progress, 18g hep lock to L AC, O2 15 Lt ViA BVM, Pulse Check NO SHOCK advised. EMS and Paramedics arrived 0656, Placed on cardiac monitor asystole Resumed CPR, Inmate was intubated by Medics, 3 Rounds of Epinephrine administered, Pulse Check asystole, Inmate was transported to Local ER with CPR in progress. OBJECTIVE: Exam: General Appearance Yes: Unconscious Generated 08110/2019 06:10 by RN Bureau of Prisons - NYM Page 1 of 2 EFTA00110350 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 08/10/2019 07:25 Provider: RN Unit: Z04 Exam: ASSESSMENT: Cardiac Arrest PLAN: New Consultation Requests: Consultation/Procedure Target Data Scheduled Target Dais Priority Translator Languaae Emergency Room 08/10/2019 08/10/2019 Emergent No Subtype: AMBULANCE Reason for Request: Cardiac arrest with CPR in progress Copay Required: No TelephoneNerbal Order: No Completed by RN on 08/10/2019 08:10 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Cosign Required: Yes Generated NY10/2019 08:10 by RN Bureau or Prisons • NYM Page 2 of 2 EFTA00110351 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 15:58 Provider. MD Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: MD Chief Complaint: Other Problem Subjective: PATIENT WAS REFERRED BY THE WARDEN FOR EVALUATION. PATIENT REPORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO REPORTS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STATES THE NUMBNESS WENT AWAY ON ITS OWN. BUT WAS VERY CONCERNING. HE DENIES RIGHT SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OR SWALLOWING. HE REPORTS NOCTURIA OF ABOUT 5 TIMES.. HE DENIES DYSURIA. HE REPORTS H OF KIDNEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEP APNEA AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HERE SINCE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE RECEIVED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-MEDICAL ISSUES. STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Seen for clinic(s): Pulmonary/Respiratory, Orthopedic/Rheumatology, Endocrine/Lipid OBJECTIVE: Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely III Nutrition No: Appears Obese Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2 No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neurologic Ginersted 07/30/2019 16:12 by MD Bureau of Prisons • NYM Page 1 of 2 EFTA00110352 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 15:58 Provider. Reg #: 76318-054 M Race: WHITE Facility: NYM MD Unit: Z01 Exam: Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current Constipation, unspecified, K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, R7303 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: Medication INsulin REG - Human Indication: Prediabetes Discontinued Medication Orders: Bat Medication 122148-NYM Insulin Reg (10 ML) 100 UNITS/ML Inj Order Date 07/30/2019 15:58 Order Date 07/30/2019 15:58 Discontinue Type: When Pharmacy Processes Discontinue Reason:new order written Indication: Copay Required: No 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 subcutaneously per sliding scale: twice daily "pill line"' for 7 days Generated 07/30/2019 16:12 by MD Bureau of Prisons • NYM Page 2 of 2 EFTA00110353 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: M Race: WHITE Provider: Reg /I: 76318-054 Facility: NYM MD Unit: 201 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT S PATIEN ALSO STAT HE DEN SPEAKING HE REPORT HE REPORTS TOPROL. HE AHS A HX OF SLEEP AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN CE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE R E HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-ME I STATES HE FEELS OTHERWISE Not Applicable Pain: MD REFERRED BY THE WARDEN FOR EVALUATION. RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY J. OWING. • Tfiki!J7 IA OF ABOUT 5 TIMES.. HE DENIES DYSURIA. H t b NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology, OBJECTIVE: Pulse: Date 07/30/2019 07/30/2019 07/30/2019 Respirations: Time Rate Per Minute 13:02 94 09:40 88 09:30 87 Location Via Machine Via Machine Date Time Rate Per Minute provides 07/30/2019 09:30 NYM 12 Blood Pressure: Date Time Value Location 07/30/2019 13:02 NYM 114/84 Left Arm 07/30/2019 09:40 NYM 125/60 Right Arm 07/30/2019 09:30 NYM 108/86 Left Arm MD MD MD MD position Cuff Size provider Standing MD Standing MD Silting MD SaO2: Date Time Value(%) Air Provider 07/30/2019 09:30 NYM 98 Room Air Weight: Date Time Lbs Kg Waist Circum. Provider MD Generated 07/302019 14:05 by MD Bureau of Prisons NYM Page 1 of 3 EFTA00110354 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: MD Unit: Z01 DAR Time 07/30/2019 09:30 NYM 194.2 88.1 MD Lb.S. Kg Waist Circurn, Pioxider 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 cutely III Nutrition No: Appears Ob Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR 1 and S2 No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0-27.9. adult, Z6827 - Current Constipation, unspecified. K5900 - Current Essential (primary) hypertension, 110 - Current - BY 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: Medication Order Date Prescriber Order Generated 07/30/2019 14:05 by MD Bureau of Prisons • NYM Page 2 of 3 EFTA00110355 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: MD Unit: Z01 New Medication Orders: Rx# Medication Magnesium Hydroxide Susp conc 800 MG/5ML Indication: Constipation, unspecified INsulin REG - Human Order lade 07/30/2019 11:12 07/30/2019 11:12 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 Indication: Prediabetes Renew Medication Orders: &,t1 Medication Order Date Prescriber Order 121836-NYM methylPR ne 4 MG Tab ( 21 count 07/30/2019 11:12 Take the tablet by mouth as Pack) directed x 6 day(s) Indication: a and neuritis, unspecified New Laboratory Requests: Details EteStiallca Due Date Priority Lab Tests - Short List-General-CBC w/diff ne Time 08/01/2019 00:00 Routine Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short Lisl-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 NUIMR ESS1PAR 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 Handout/Topic 07/30/2019 Counseling Access to Care 07/30/2019 Counseling Copay Required: No TelephoneNerbal Order: No Completed by Plan of Care Cosign Required: No MD on 07/30/2019 14:05 aic Outcome Verbalizes Understanding Verbalizes Understanding Generated 07/30/2010 14:05 by MD Bureau of Prisons NYM Page 3 of 3 EFTA00110356 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: M Race: WHITE Provider: Reg #: 76318.054 Facility: NYM MD Unit: 201 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT JS PATIE ALSO STAT HE DENI SPEAKING HE REPORT HE REPORTS TOPROL. HE AHS A FIX OF SLEEP ISNCE HE HASB EEN INFORME DHIM THAT WE R HIM TONIGHT.. HE REPORT OTHER NON-ME STATES HE FEELS OTHERWISE Not Applicable Pain: MD REFERRED BY THE WARDEN FOR EVALUATION. RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. SIDED WEAKNESS, DIPLOPIA. FACIAL DROOP, DIFFICULTY OWING. •.-Air IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. H .1t. NEY STONES. HX OF HTN FOR WHICH HE WAS TAKING AND STATED HE HAS NOT SLEPT FOR 3 WEEKS CE HE DIE NOT HAVE ACCESS THI CPAP MACHINE. I HIS CPAP MACHINE AND IT WILL BE GIVEN TO ES. Seen for clinic(s): Endocrine/Lipid. Orthopedic/Rheumatology, Respiratory OBJECTIVE: Pulse: Date 07/30/2019 07/30/2019 07/30/2019 Respirations: Date 07/30/2019 Time Rate Per Minute 13:02 94 09:40 88 09:30 87 Blood Pressure: lac_ation Via Machine Via Machine Time Rate Per Minute Provider 09:30 NYM 12 Date im Value Location 07/30/2019 13:02 NYM 114/84 Left Arm 07/30/2019 09:40 NYM 125/60 Right Arm 07/30/2019 09:30 NYM 108/86 Left Arm SaO2: Date 07/30/2019 Weight: Date Timo Value(%) Air 09:30 NYM 98 Room Air MD Position Cuff Size Provider Standing Standing Sitting Provider Time Lge. Kg Waist Circum Provider MD MD MD MD MD MD MD Generated 07/30/2019 14:05 by MD Ehlteall of Prisons • NYM Page 1 of 3 EFTA00110357 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Binh: 01/20/1953 Encounter Date: 07/30/2019 11:12 Sex: Provider: Reg if: M Race: WHITE Facility: MO Unit: 76318-054 NYM 201 Data Time 07/30/2019 09:30 NYM 194.2 88.1 Lk Kg Waist Circum. Provider MD 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, Unk cutely III Nutrition No: Appears Ob Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR)pJQ S1 and S2 No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0-27.9, adult, 26827 - Current Constipation, unspecified. K5900 - Current Essential (primary) hypertension. 110 - Current - BY HX. Flyperlipidemia, 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: EAft Medication Order Date Prescriber Order Generated 07/30/2019 14.05 by MD Bureau of Prisons - NYM Page 2 of 3 EFTA00110358 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: MD Unit. Z01 New Medication Orders: Rx# Medication. Order Date Prescriber Order Magnesium Hydroxide Susp conc 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: Rx# Medication 121836-NYM methylP ne 4 MG Tab ( 21 count 07/30/2019 11:12 Pack) Indication: is and neuritis, unspecified New Laboratory Requests: Details Frequency Due Date Priority Lab Tests - Short List-General-CBC w diff ro e Time 08/01/2019 00:00 Routine Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short List-General-Comprehensiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic New Radiology Request Orders: Details 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 Order Date Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format Handout/Tooic 07/30/2019 Counseling Access to Care 07/30/2019 Counseling Plan of Care Copay Required: No TelephoneNerbal Order: No Completed by Cosign Required: No MD on 07/30/2019 14:05 Prescriber Order Take the tablet by mouth as directed x 6 day(s) R 2-3 MINUTES 3 DAYS AGO. 62‘ Outcome Verbalizes Understanding Verbalizes Understanding Generated 07/302019 14:05 by MD Bureau of Prisons NYM Page 3 of 3 EFTA00110359 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 15:58 Facility: NYM Amendment made to this note by MD on 07/30/201916:12. Bonsai of Prisons • NYM EFTA00110360