EFTA00110421.pdf

Bureau of Prisons Health Services Vision Screens Reg 0: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Vision Screen on 07/09/2019 12:52 Blindness: Distance Vision: OD: 20/100 OS: 20/70 OU: Near Vision: OD: OS: OU: With Corrective Distance Vision: OD: OS: OU: Near Vision: OD: OS: OU: Present Glasses - Distance Refraction - Distance Sphere Cylinder Axis Add Sphere Cylinder Axis Add R: R: L: L: Color Test: Tonometry: R: L: Comments: Needs evaluation with optometrist. Orl9 Entered: 07/09/2019 12:54 EST MLP Generated 08/10/2019 11:02 by Bureau of Prisons • NYM Pagel°, 1 EFTA00110421 Bureau of Prisons Health Services Immunizations Begin Date: 07/07/2019 End Date: 08/10/2019 Reg 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD immunization immunization Date Administered Location osmium DrusaIS. lag ExaDsta Hepatitis A and B (TwinRx) History Unknown Orig Entered: 07/09/2019 12:51 EST MLP Measles/Mumps/Rubella Series History Unknown Orig Entered: 07/09/2019 12:51 EST . MLP Smallpox Series History Unknown Orig Entered: 07/09/2019 12:51 EST Tetanus -. MLP History Unknown Orig Entered: 07/09/2019 12:51 EST MLP Varicella Series History Unknown Orig Entered: 07/09/2019 12:51 EST Total: 5 MLP Generated 08/101201911:02 by RN/IC/P/10C Bureau of Prisons - NYM Page 1 of 1 EFTA00110422 Bureau of Prisons Health Services Medical Duty Status Reg it: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Housing Status confined to the living quarters except _meals _pill line treatments Exp. Date: on complete bed rest: _bathroom privileges only Exp. Date: X cell: cell on first floor single cell X lower bunk airborne infection isolation Exp. Date: 10/09/2019 other: Exp. Date: Physical Limitation/Restriction all sports Exp. Date: weightlifting: upper body lower body Exp. Date: cardiovascular exercise: _running _jogging _walking _softball Exp., Date: football basketball _handball stationary equipment other: Exp. Date: May have the following equipment in his / her possession: Equipment Start Date End Date Return Date C-Pap 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P1131281381ED. Work Restriction / Limitation: Cleared for Food Service: Yes X No Restrictions Comments: N/A MD 07130/2019 Health Services Staff Date Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 14: 76318-054 Quarters: Z04 ALL EXPIRATION DATES ARE AT 24:00 Generated 08/10/2019 11:02 by Bureau of Prisons NYM Page 1 of 1 EFTA00110423 Bureau of Prisons Health Services Medical Duty Status Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Housing Status confined to the living quarters except _meals _pill line _treatments Exp. Date: on complete bed rest: _bathroom privileges only Exp. Date: X cell: cell on first floor _single cell X lower bunk airborne infection isolation Exp. Date: 10/09/2019 other: Exp. Date: Physical Limitation/Restriction all sports Exp. Date: weightlifting: upper body lower body Exp. Date: cardiovascular exercise: _running _jogging _walking _softball Exp. Date: _football _basketball _handball _stationary equipment other: Exp. Date: May have the following equipment in his / her possession: Work Restriction / Limitation: Cleared for Food Service: Yes X No Restrictions Comments: N/A MLP 07/09/2019 Health Services Staff Date Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Quarters: Z04 ALL EXPIRATION DATES ARE AT 24:00 Generated 08110/2019 1102 by Bureau of Prisons - NYM Page 1 of 1 EFTA00110424 Bureau of Prisons Health Services Medication Summary Historical 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 Medications listed reflect prescribed medications from the begin date to end date on this report. Allergies: Denied Active Prescriptions Bisacodyl E.C. 5 MG TAB Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10 days Rx#: 121757-NYM Doctor: MLP Start: 07/09/19 Exp: 07/19/19 D/C: 07/12/19 Pharmacy Dispensings: 10 TAB in 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 in 29 days Docusate Sodium 100 MG Cap Take one capsule (100 MG) twice daily by mouth with plenty of water Rx#: 122084-NYM Doctor. MD Start: 07/26/19 Exp: 01/22/20 Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML shake well take 2 tablespoonful twice daily by mouth Rx#: 121835-NYM Doctor: Start: 07/12/19 Exp: 07/14/19 MD Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML shake well take 10m1 by mouth twice daily AS NEEDED Rx#: 122150-NYM Doctor. Start: 07/30/19 Exp: 10/28/19 methylPREDNISolone 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 MD Pharmacy Dispensings: 30 CAP in 15 days 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 08/10/2019 11:02 by Bureau of Prisms NYM Page 1 of 2 EFTA00110425 Complex: NYM--NEW YORK MCC Inmate: EPSTEIN, JEFFREY EDWARD Begin Date: 07/07/2019 End Date: 08/10/2019 Reg g: 76318-054 Quarter Z04-206LAD Active Prescriptions Omega 3 (Vascepa) 1 GM Capsule Take two capsules (2 GM) twice daily by mouth with food Rx#: 121885-NYM Doctor: Start: 07/17/19 Exp: 01/13/20 MD Pharmacy DIspensings: 180 Cap in 24 days Insulin Reg (10 ML) 100 UNITS/ML Inj Inject regular insulin subcutaneously per sliding scale: twice daily "'pill line"' for 7 days "'pill line"' Fta: 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 subcutaneously per sliding scale: each morning for 7 days "'pill line"' "'pill line"' Fbdi: 122160-NYM Doctor: MD Start: 07/31/19 Exp: 08/07/19 Pharmacy DIspensIngs: 0 ML in 10 days Generated 08/10/2019 11:02 by Bureau of Prisons - NYM Page 2 of 2 EFTA00110426 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 Race: WHITE Facility: NYM Encounter Date: 07/26/2019 07:54 Provider: DDS Unit: H01 ASSESSMENTS: Health Problems as of Dental Health History Encounter date: 07/26/2019 07:54 Health Problems Health Problem Status Hyperlipidemia, unspecified Current HYPERTRIGLYCERIDEMIA Sleep apnea Current Constipation, unspecified Current Low back pain Current Neuralgia and neuritis, unspecified Current No Diagnosis Current Injury, unspecified Current R/O self inflicted injuries. Medical History as of Dental Health History Encounter date: 07/26/2019 07:54 Medical History: Allergies: Denied Seizures: Denied Diabetes: Denied Cardiovascular: Denied CVA: Denied Hypertension: Denied Respiratory: Denied Sickle Cell Anemia: Denied Carcinoma/Lymphoma: Denied HIV History: When Tested: 2019 Test Result: Negative When Diagnosed AIDS: Last CD4: Comments: Hepatitis: Denied Generated 07/213/2019 07:59 by DOS Bureau of Prisons - NY M Page 1 of 3 EFTA00110427 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: DDS Unit H01 Other Infectious Diseases: Syphilis: No Syphilis Last Treatment: N/A Genital Warts: No Chlamydia: Yes Gonorrhea: No Herpes: No Chicken Pox: Yes Other: No Comments: Chlamydia in 2015, treated Chicken pox in childhood Other Health Issues: Other Medical Conditions And Treatment: sleep apnea Current Medical Conditions: Other Current Treatments: Pregnant: N/A Dental Observations as of Dental Health History Encounter date: 07/26/2019 07:54 History: Alcohol: No Methamphetamine: No Tobacco products: No Other drugs: No Sensitive teeth: No Bleeding gums: Yes Food impaction: Yes Pain around oar: 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: Genesaled 07/26/2019 07.59 Lq DDS Bureau of Prisons NYM Page 2 of 3 EFTA00110428 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: DDS Unit: H01 Cardiac Condition Requiring Prophylaxis: No Prosthetic joint(s): No Radiation history of head or neck: No Excessive bleeding: No Bisphosphonates: No Comments: Medications as of Dental Health History Encounter date: 07/26/2019 07:54 Medications: Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take one capsule (100 MG) by mouth twice daily for 30 days Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by mouth with food OTCs: Listing of all known OTCs this inmate is currently taking. Instructed inmate how to obtain medical, dental, and mental health care. Copay Required:No Cosign Required: No TelephoneNerbal Order: No Completed by DDS on 07/26/2019 07:59 Generated 07/26/2019 07 59 by DOS Bureau or Prisons - NYM Pape 3 of 3 EFTA00110429 Bureau of Prisons Health Services Dental A&O Exam Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Bath: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/26/2019 07:47 Provider: Reg #: 76318-054 Facility: NYM DDS Unit H01 Reviewed Health Status: Yes Occlusion: Class I Oral Hygiene: Fair CPITN: 3 2 3 3 1 2 1 3 Hard and soft tissue examination performed and documented on BP618 form: Yes Head & Neck/Soft Tissue within normal limits? No Comments: moderate to advanced upper posterior gingival recession Decayed: Missing: Filled: 0 1 14 Comments: Lower anterior crowding Approved for hygiene appointment and radiographs: Yes Instructed inmate how to obtain routine and emergency dental care. Oral hygiene instructions given: Yes Dental A&O Screening Exam findings entered on EPSTEIN, JEFFREY EDWARD by DDS on 07/26/2019 07:47. Generated 07/26/2019 0800 by DOS Bureau ol Prisons - NYM Page 1 or 1 EFTA00110430 Bureau of Prisons Health Services Dental Soap/Admin Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/18/2019 13:48 Provider: Dental Ant Unit: ZOS Screening encounter at Dental Clinic. Reason Not Done: Unavailable Comments: Patient has had several call outs for his Dental A & O screening but has not been escorted to the dental clinic. Cosign Required: No Completed by Dental Asst on 07/19/2019 13:49. Generated 07/191201913:49 by Denial 'Bureau ol Prisons • NYM Page 1 ot I EFTA00110431 Federal Bureau of Prisons U.S. Medi Prisons "'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 CHEMISTRY Sodium Potassium Chloride CO2 BUN Creatinine eGFR (IDMS) 137 4.7 99 27 17 1.05 >60 137-148 3.5-5.0 99-114 22-30 7-22 0.66.1.25 mmol/L mmol/L mmol/L mmol/L mg/dL mg/dL GFR units measured as ml/min/1.73 m^2. If African American multiply by 1.210. A calculated GFR <60 suggests chronic kidney disease if found over a 3 month period. Calcium 9.8 8.5-10.9 mg/dL Glucose 102 70-110 mg/dL AST H 57 11-55 U/L ALT 62 11.66 U/L Alkaline Phosphatase 64 41-133 U/L Bilirubin, Total 1.1 0.2-1.3 mg/dL Total Protein 7.3 6.0-8.2 g/dL Albumin 4.4 3.6-5.1 g/dL Globulin 2.9 2.0-3.7 g/dL Alb/Glob Ratio 1.50 1.00-2.30 Anion Gap 10.2 9.0-19.0 BUN/Creat Ratio 16.1 5.0.30.0 Cholesterol H 216 <200 mg/dl.. Triglycerides H 413 10-150 mg/dL Calculation of L0L 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 Chol/HDL Ratio H 6.9 0.0.4.0 HEMATOLOGY WBC 7.6 4.3-11.1 K/uL NRBC% 0.0 RBC 5.42 4.46-5.78 M/uL Hemoglobin 15.6 13.6-17.6 g/dL Hematocrit 47.8 40.2-51.4 MCV 88.2 82.5-96.5 n_ MCH 28.8 27.1-34.9 Pg MCHC 32.6 33.0-37.0 g/dL RDW-CV 12.8 12.0-14.0 Platelet 338 130-374 K/uL FLAG LEGEND L=Low L!=Low Critical H=High H!=High Critical A=Abnormal Al =Abnormal Critical Page 1 of 3 EFTA00110432 Federal Bureau of Prisons U.S. Medi al Prisons ***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 07/10/201914:46 LIS ID 188191004 HEMATOLOGY MPV 10.4 6.9.10.5 n_ Neutrophds % 58.7 Therapeutic decision making should be based on absolute values, rather than percentages Lymphocytes % 25.0 Monocytes % 11.1 Eosinophils % 4.1 Basophils % 0.8 Immature Granulocytes % 0.3 0.0-5.0 Neutrophils # 4.4 1.9-6.7 K/uL Lymphocytes # 1.9 1.3-3.7 K/uL Monocytes # 0.8 0.3-1.1 K/uL Eosinophds # 0.3 0.0-0.5 K/uL Basophils # 0.1 0.0-0.1 K/uL Immature Granulocytes # 0.02 0.00-0.50 10"3/uL HEMOGLOBIN AMC Hemoglobin A1C H 6.3 <5.7 5.7 - 6.4 Increased Risk > 6.4 Diabetes SEROLOGY RPR Non-Reactive Non-Reactive Results may be affected in patients with severely advanced immunosuppression. FLAG LEGEND L=Low L!=Low Critical H=High H!=High Critical A=Abnormal A! =Abnormal Critical Page 2 of 3 EFTA00110433 O Federal Bureau of Prisons U.S. Medi I Prisons '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 - 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 EFTA00110434 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 07/141201918:12. Bureau of Prisons • NYM EFTA00110435 BP-5356.060 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. NYM-NEW YORK MCC EFTA00110436 BP-A0618 A&O DENTAL EXAMINATION JUN 16 U.S. DEPARTMENT OF JUSTICE (Initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS SIN I34 3 4 5 6 7 6 9 10 11 1213 11 15 32 31 Gt1ff'1?11!11 1 iI III fli 11 C 3D 2D 28 27 26 25 21 23 22 21 20 19 18 17 Occlusion: Oral Hygiene: Good r'arFz 00r GRIN: 3 Z. 3 2- 9 Head & Neck / Soft Tissue: M: I , F : Classification: C Pain Scale: /10 Dental Prostheses at Intake: Type: C Type: Age: Condition: Comm 4 2 it Q SS i Lasted - C.--,..AirA an /71.5 /Vs' on absent/-e Seiv-e- at criyolim oipsetle4 Intra-oral Photos Taken: Yes 0 Radiographs Taken: (Docanent findings on MO encotrder) Yes No Instructed how to obtain urgent and non-urgent dental care: Yes: / No: Treatment Priorities: None: Ncn-urgent non-urgent Urgent Referred to Sick Call: Radiographs authorized: PM: Prophylaxis authorized: Yes I No (Approval valid 18 months from examination date) BWs: Pancras: Patient Name:k I C O 3 — cich E. Dentist Si nature: 1:47S FictsfNuter 76 3 ISE- 051/41 Institution: MCC NEW YORK Date: 7- 26 -I 9. Signature Block/Stamp: DDS. PDF Prescribed by P64C* let Uental cer MCC New York Replaces BP-A0618 of JUN 10 EFTA00110437