EFTA00110400.pdf

Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: H01 Thorax: Contour Normal:Yes Increased AP Diameter: No Asymmetrical Expansion:No Lungs Clear: Yes Wheezes: No Crackles: No Rhonchi: No Rates: No Accessory Muscle Use: No Comments: Spine: Deformity: No Full ROM:Yes Tenderness: No Comments: Cardiovascular. RRR: Yes Normal S1/52: Yes Murmurs: No Carotid Bruits:No JVD: No Arteries: Rlaht. 1st Radial: Femoral: Dorsalis Pedis: Post Tibialis: Comments: Generated 07/09/2019 13:03 by MLP Bureau of Prisons - NYM Page 10 ol 13 EFTA00110400 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: . MLP Unit: H01 Abdomen: Normal Contour:Yes Scaphold: No Obese: No Gravid: No Hernias: No Bruits: No Masses:No Scars: No Tenderness: No Organomegaly: No Active Bowel Sounds: Yes Comments: Extremities: Nails Clubbing: No Nails Cyanosis: No Lower Extremity Edema - Right: None Lower Extremity Edema - Left: None Atrophy: No Amputations: No Other Deformities: No Varicosities:No Calf Tenderness: No Pulse Deficit: No Strength: Eight Left Ann: Leg: Full ROM: Right Lett Arm: Yes Yes Leg: Yes Yes Comments: Generated 07/0912019 13O3 by MLP Bureau of Prisons • NYM Par 11 01 13 EFTA00110401 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: H01 Reflexes: Right LA S 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: Lim 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 07.092019 13.03 by Bureau of Prisons • NYM Page 12 of 13 EFTA00110402 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/09/2019 12:35 Provider: MLP Reg #: 76318-054 Facility: NYM Unit: H01 Cleared For Food Services: Yes Health Problems Newly Identified During This Encounter: Health Problem Constipation, unspecified - Current - New Medication Orders: Rd Medication Order Date Prescriber Order Bisacodyl E.C. Tablet 07/09/2019 12:35 5 mg Orally at bedtime PRN x 10 day(s) Indication: Constipation, unspecified Disposition: Follow-up at Sick Call as Needed Instructed inmate how to obtain medical, dental, and mental health care. Copay Required: No Cosign Required: Yes TelephoneNerbal Order: No Completed by MLP on 07/09/2019 13:03 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 07/09/2019 13.03 by MLP Bureau of Prisons NYM Page 13 of 13 EFTA00110403 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/09/2019 12:35 Provider: . MLP Facility: NYM Cosigned by MD on 07/11/2019 22:41. Bureau of Prisons - NYM EFTA00110404 Bureau of Prisons Health Services Inmate Local Hospital Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD SENSITIVE BUT UNCLASSIFIED — This information is confidential and must be appropriately safeguarded. Transfer To: Transfer Date: 08/10/2019 Health Problems Health Problem Status Hyperlipidemia, unspecified Current HYPERTRIGLYCERIDEMIA Sleep apnea Current Essential (primary) hypertension Current BY HX. Constipation, unspecified Current Low back pain Current Neuralgia and neuritis, unspecified Current No Diagnosis Current Prediabetes Current Injury, unspecified Current R/O self inflicted injuries. Body mass index (BMI) 27.0-27.9, adult Current Medications: All medications to be continued until evaluated by a physician unless otherwise indicated. Bolded drugs required for transport. Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take one capsule (100 MG) by mouth twice daily for 30 days Docusate Sodium 100 MG Cap Exp: 01/22/2020 SIG: Take one capsule (100 MG) twice daily by mouth with plenty of water Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML Exp: 10/28/2019 SIG: shake well take 10ml by mouth twice daily AS NEEDED Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by mouth with food OTCs: Listing of all known OTCs this inmate is currently taking. None Pending Appointments Data Time Activity Provider 07/24/2019 00:00 Clinical Encounter Optometrist 01/07/2020 00:00 Chronic Care Visit Mid-Level Provider 07/01/2020 00:00 Chronic Care Visit Physician 01 07/09/2020 00:00 PPD Administration Nurse Pending Non-Medication Orders: Order Order Date freouency Duration Details EKG 07/06/2019 One Time 66 y/o male Fecal Occult Blood 07/06/2019 One Time 3 different stools TB Clearance: Yes Last PPD Date: 07/09/2019 Induration: 0mm Last Chest X-Ray Date: Results: TB Treatment: Sx free for 30 days: Yes TB Follow-up Recommended: No Sickle Cell: Sickle Cell Trait/Disease: No Generated 08/10/2019 07:00 by RN Bureau of Prisons - NYM Page 1 of 2 EFTA00110405 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD SENSITIVE BUT UNCLASSIFIED — This information is confidential and must be appropriately safeguarded. Llmitations/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. Address 1: Address 2: City/State/Zip: NEW YORK, New York 10007 Name/ Title of Person Completing Form: RN Date: 08/10/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg ft: 76318-054 DOB: 01/20/1953 Sex: M Generated 08/1072019 07:00 by RN Bureau or Prisons - NYM Page 2 01 2 EFTA00110406 Bureau of Prisons Health Services Vitals All Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Temperature: Rata Ilms Fahrenheit Celsius Location 07/24/2019 13:12 NYM 97.8 36.6 Oral Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 NYM 97.5 36.4 Oral Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM 97.3 36.3 Oral Orig Entered: 07/09/2019 12:51 EST Pulse: Date Time 07/30/2019 13:02 Rate Per Minute Location 94 Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:40 Orig Entered: 07/30/2019 07/30/2019 09:30 Orig Entered: 07/30/2019 07/28/2019 20:28 Orig Entered: 07/28/2019 07/28/2019 06:57 Orig Entered: 07/28/2019 07/24/2019 13:12 Orig Entered: 07/24/2019 07/23/2019 06:30 Orig Entered: 07/23/2019 07/09/2019 12:49 Orig Entered: 07/09/2019 Respirations: Rate 07/30/2019 Time 09:30 NYM MLP MLP MLP 88 Via Machine 13:04 EST 87 Via Machine 12:59 EST 81 20:29 EST 82 06:58 EST 83 13:14 EST 92 08:33 EST 82 12:51 EST Provider MLP MLP MLP Rhythm Provider MD MD MD RN RN Via Machine Regular . MLP Via Machine Regular . MLP Via Machine Regular MLP Rate Per Minute Provider 12 Orig Entered: 07/30/2019 12:59 EST 07/28/2019 20:28 NYM Orig Entered: 07/28/2019 20:29 EST 07/28/2019 06:57 NYM Orig Entered: 07/28/2019 06:58 EST 07/23/2019 06:30 NYM Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM Orig Entered: 07/09/2019 12:51 EST 14 14 16 16 MD MD RN RN RN MLP . MLP MLP . MLP RN MD MD MD RN RN MLP MLP MLP Generated 00/10/2019 11:02 by Bureau of Prisons - NYM Page I of 3 EFTA00110407 Begin Date: 07/07/2019 Reg #: 76318-054 End Date: 08/10/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Blood Pressure: galg Time Value 07/30/2019 13:02 NYM 114/84 Location Position Loft Arm Standing Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:40 NYM 125/60 Right Arm Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:30 NYM 108/86 Left Arm Orig Entered: 07/30/2019 12:59 EST 07/28/2019 20:28 NYM 157/91 Orig Entered: 07/28/2019 20:29 EST 07/28/2019 06:57 NYM 138/80 Orig Entered: 07/28/2019 06:58 EST 07/24/2019 13:12 NYM 132/89 Right Arm Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 NYM 140/85 Right Arm Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM 117/66 Right Arm Orig Entered: 07/09/2019 12:51 EST Standing Sitting Sitting Sitting Sitting Blood Glucose: nate It Maktalak11) bee 08/04/2019 08:30 156 Non-Fasting Orig Entered: 08/04/2019 09:08 EST 08/02/2019 06:30 97 Non-Fasting Orig Entered: 08/02/2019 08:16 EST 08/01/2019 06:30 103 Non-Fasting Orig Entered: 08/01/2019 09:00 EST 07/31/2019 06:15 108 Non-Fasting Orig Entered: 07/31/2019 08:36 EST MLP MLP MLP MLP MLP MLP Cuff Sin Provider MD MD MD RN RN Adult-regular Adult-regular Adult-regular MLP MLP MLP Regular Insulin Provider RN SaO2: Value(%) Air Provider 07/30/2019 09:30 NYM 98 Room Air Orig Entered: 07/30/2019 12:59 EST MD 07/28/2019 20:28 NYM 98 Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 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 MLP 07/23/2019 06:30 NYM 96 Room Air . MLP Orig Entered: 07/23/2019 08:33 EST MLP 07109/2019 12:49 NYM 97 Room Air . MLP Orig Entered: 07/09/2019 12:51 EST MLP Height: Generaled 08110/2019 11 02 by Bureau of Prisons • NYM MD RN RN MD MD MD RN RN RN MLP MLP MLP Page 2 of 3 EFTA00110408 Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date Time Inches Cm Provider 07/09/2019 12:49 NYM 70.0 . 177.8 MLP Orig Entered: 07/09/2019 12:51 EST MLP Weight: Date Time kke hg Waist Circum, provider 07/30/2019 09:30 NYM 194.2 88.1 MD Orig Entered: 07/30/2019 12:59 EST 07/09/2019 12:49 NYM 194.4 88.2 Orig Entered: 07/09/2019 12:51 EST MLP MD MLP Generated 00110/2019 11.02 by Bureau of Prisons - NYM Page 3 of 3 EFTA00110409 Bureau of Prisons Health Services PPDs Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Minim Legalism 07/06/2019 21:39 Right Forearm Orig Entered: 07/06/2019 21:43 EST Total: 1 Provider PA-C PA-C Reading: Jnduration Provider 07/09/2019 12:47 0 mm . MLP Orig Entered: 07/09/2019 12:47 EST MLP Generated 0811012019 11:02 by RNAOP/IDC Bureau of Prisons • NYM Page 1 of 1 EFTA00110410 76318-054 EPSTEIN. JEFFREY Medication Orders Medication Administration Record JULY 2019 Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Ord. Dee 07/30119 1421 Esp. Dane 07(31/19 10 01 NYM 112148- NYM MD Inject regular Insulin subcutaneously per sliding scale: twice daily "'pin line" for 7 Pays frauitn Reg (10 kr4.1100 UNITS/SAL IN PRN .4 o Ord. Date 0701/19 10.00 Exp. Date 08107/19 09:59 NYM 112160- NYM MC Inject regular Insulin subcutaneously per sliding seal*: each morning for 7 days "'pill boe••• Ineutn Reg (10 MLI 100 UNITSAIL inj PRN Providers: YJ = Documentation Codes. ORD = Order I NI = Dose Not Indicated Registration 4: 76318-054 Pt. Name: EPSTEIN. JE'FFREY DOW 0120/53 Report information is current as of the date and time of printing: 08/10/2019 11:02 EST EFTA00110411 76318-054 EPSTEIN. JEFFREY Medication Ordors Ord. Oase M3 07/31/19 1000 Injocl-egular insu:In subcutaneously per Exp. Dow sliding into: posh monolog tor 7 days —pill 08/07119 09 59 NYM 122160- NYM Insulin Reg (10 ML) 100 UNITS/ML Phi Medication Administration Record AUGUST 2019 Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 PON Providers: YJ = Documenta5on Codes ORD = Order I NI = Dose Nol indicated Registration 76318-054 Pt. Name: EPSTEIN. JEST REY DOB: 01/20153 Report information Is current as of tho dato and lime of prinling: 08/10/2019 11 02 EST EFTA00110412 Bureau of Prisons Health Services Devices and Equipment Start Date: 07/07/2019 Stop Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Device/Equipment Start Date Stop Date pate 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 08/10/2019 II:02 by RN/IOP/IDC Bureau of Prisons • NMI Page 1 of EFTA00110413 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 Data Jntervention 07/12/2019 13:25 MEDROL DOSE PACK Orig Entered: 07/12/2019 13:28 EST Pain Quality Location pa post Provider Shooting Back-Middle 5 MD MD Generated 08/10/201911:02 by FtN/1OPADC Bureau of Prisons - NYM Page 1 or 1 EFTA00110414 Bureau of Prisons Health Services Modified Diet Request Types of Diets: Clear Liquid Exp Date: Low Fat Exp Date: Mechanical Soft Exp Date: Low Cholesterol Exp Date: Low Triglyceride Exp Date: Renal Exp Date: Full Liquid Exp Date: Sodium Controlled Exp Date: Snack Exp Date: Diabetic Exp Date: Calorie Controlled Exp Date: X Other: FISH ALLERGIES. Exp Date: 07/30/2020 Comments: MD Health Service Staff EPSTEIN, JEFFREY EDWARD 76318-054 07/3012019 Inmate Name Reg# Date Generate0 07/30/2019 14:57 by MD Bureau ot Prisons • NYM Page 1 ol 1 EFTA00110415 Bureau of Prisons Health Services Allergies Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Moray Date Noted Reaction No Known Allergies 07/06/2019 Orig Entered: 07/06/2019 21:40 EST PA-C Total: 1 Generated 08/10/2019 11:02 by Bureau of Prisons - NYM Page 1 of 1 EFTA00110416 Bureau of Prisons Health Services Patient Education Assessments & Topics Reg N: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Assessment 07/09/2019 Total: 1 Assessments Learns Best By Primary Language Years of Education Flarriers To Education Speaking/Listening English 12 None Orig Entered: 07/09/2019 12:52 EST Date Initiated 07/30/2019 Ode 07/30/2019 Odg 07/28/2019 Odg 07/28/2019 Odg 07/24/2019 Odg 07/24/2019 Ode 07/23/2019 Orig 07/23/2019 Orig 07/14/2019 Odg 07/12/2019 Format Counseling Entered: 07/30/2019 Counseling Entered: 07/30/2019 Counseling Entered: 07/28/2019 Counseling Entered: 07/28/2019 Counseling Entered: 07/24/2019 Counseling Entered: 07/24/2019 Counseling Entered: 07/23/2019 Counseling Entered: 07/23/2019 Counseling Entered: 07/14/2019 Counseling Generated 08/1012019 11:02 by fiandout/Toplc Access to Care 13:33 EST Plan of Care 13:34 EST Plan of Care 07:22 EST Plan of Care 20:30 EST Access to Care 13:23 EST Preventive Health 13:23 EST Access to Care 09:04 EST Plan of Care 09:04 EST Diagnosis 18:11 EST Diagnosis RNAORIDC Topics Outcome Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Bureau of Prisons • NY1A Page 1 at 2 Provider Provider EFTA00110417 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Topics outcona Handout/700c. Date Initiated format Provider Orig Entered: 07/12/2019 13:33 EST Total: 10 Generated 0B.10/2319 11 02 by RNfl0P/IDC Bureau o' Prisons • tdrili Page 2 c' 2 EFTA00110418 Bureau of Prisons Health Services Blood Glucose Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD (Reference Range: Random or Fasting 70 - 100, 2 hour post-prandial 70 - 140) Date Time Value Tvoe 08/04/2019 08:30 NYM 156 Non-Fasting Orig Entered: 08/04/2019 09:08 EST RN 08/02/2019 06:30 NYM 97 Non-Fasting Orig Entered: 08/02/2019 08:16 EST MLP 08/01/2019 06:30 NYM 103 Non-Fasting Orig Entered: 08/01/2019 09:00 EST MLP 07/31/2019 06:15 NYM 108 Non-Fasting Orig Entered: 07/31/2019 08:36 EST MLP Total: 4 Comment% Generated 08110/2019 11:02 by RN/IOP/IDC Bureau of Pitons - NYM Page 1 of 1 EFTA00110419 Bureau of Prisons Health Services Health Problems Reg it 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Description Hyperlipidemia, unspecified 07/12/2019 13:48 EST HYPERTRIGLYCERIDEMIA Sleep apnea 07/12/2019 13:56 EST Essential (primary) hypertension 07/30/2019 13:13 EST BY HX. Constipation, unspecified 07/09/2019 12:58 EST MLP MD MD MD Low back pain 07/12/2019 13:30 EST MD Neuralgia and neuritis, unspecified 07/12/2019 13:30 EST MD No Diagnosis 07/09/2019 10:28 EST PhD/Chief sychologist Prediabetes 07/30/2019 13:26 EST MD Injury, unspecified 07/23/2019 09:04 EST MLP R/O self inflicted injuries. Body mass Index (BMI) 27.0-27.9, adult 07/30/2019 13:14 EST Total: 10 MD &ia Coda Tynp Current ICD-10 ICD-10 ICD-10 ICD-10 ICD-10 ICD-10 I DSM-IV ICD-10 ICD-10 ICD-10 Cada Nag Date Status E785 07/12/2019 Current G4730 07/12/2019 Current 110 07/30/2019 Current K5900 07/09/2019 Current M545 07/12/2019 Current M792 07/12/2019 Current No Dx 07/09/2019 Current R7303 07/30/2019 Current T1490 07/23/2019 Current Z6827 07/30/2019 Current Generated 09/10/2019 11:02 by RNOOPADC Bureau of Prisons - NYM Page 1 of 1 EFTA00110420