EFTA00121315.pdf

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: 07/23/2019 06:20 Provider: MLP Unit: H01 Injury Assessment - Non-work related encounter performed at Health Services. SUBJECTIVE: INJURY 1 Provider: MLP Date of Injury: 07/23/2019 01:27 Date Reported for Treatment: 07/23/2019 08:25 Work Related: No Work Assignment: UNASSG Pain Location: Pain Scale: 0 Pain Qualities: Where Did Injury Happen (Be 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 OBJECTIVE: Temperature: Data Time Fahrenheit Celsius Location provider 07/23/2019 06:30 NYM 97.5 36.4 Oral MLP Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/23/2019 06:30 92 Via Machine Regular . MLP Respirations: Date Time Rate Per Minute Provider 07/23/2019 06:30 NYM 16 MLP Blood Pressure: Date Time Value Location Position Cuff Size Provider 07/23/2019 06:30 NYM 140/85 Right Arm Sitting Adult-regular MLP SaO2: Date Time Value(%). Air Provider 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 07/2312019 09:05 by MLP Bureau of Prisons - NYM Page 1 of 2 EFTA00121315 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: MLP Unit: H01 Exam: Acutely HI Pulmonary Auscultation Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally No: Crackles, Rhonchi, Wheezing Exam 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 inches 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 diameter(mild). As per information from custody staff inmate Epstein was found in his cell with a rope around his neck and sitting on the floor. Inmate is currently placed on suicide watch. ASSESSMENT: Injury, unspecified, T1490 - Current - RIO self inflicted injuries. PLAN: Disposition: Follow-up at Sick Call as Needed Placed on Suicide Watch Follow-up in 2-4 Hours Other: For follow up with psychology service. Patient Education Topics: Date Initiated Format Handout/Topic Provider 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 Completed by . MLP on 07/23/2019 09:05 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 07/23/2019 09:05 by MLP Bureau of Prisons - NYM Page 2 of 2 EFTA00121316 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: 07/23/2019 06:20 Provider: MLP Facility: NYM Cosigned by MD on 07/23/2019 15:44. Bureau of Prisons - NYM EFTA00121317 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: 07/14/2019 17:36 Provider: MD Unit: Z05 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 TRIGL WAS 800 , NOW 431. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS DUE TO THEIR GI SIDE EFFECTS. HX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. 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 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: Seen for clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid Added to clinic(s): Orthopedic/Rheumatology, 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 07/1412019 18:11 by MD Bureau of Prisons - NYM Page 1 of 3 EFTA00121318 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/14/2019 17:36 Provider: M Race: WHITE Reg #: 76318-054 Facility: NYM 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: M/R/G Abdomen Auscultation Yes: Normo-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: Medication Omega 3 ( Vascepa) 1 GM Capsule Indication: Hyperlipidemia, unspecified New Laboratory Requests: DetaiK Lab Tests-H-Hemoglobin Al C Lab Tests-L-Lipid Profile Additional Information: Generated 07/14/2019 18:11 by MD Bureau of Prisons - NYM Order Date 07/14/2019 17:36 Freauency One Time Prescriber Order TAKE 2 CAPS Orally - Two Times a Day x 180 day(s) -- TAKE WITH FOOD. pue Date priority 10/10/2019 00:00 Routine Page 2 of 3 EFTA00121319 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/14/2019 17:36 Provider: Reg #: 76318-054 Facility: NYM MD Unit: Z05 FASTING. Lab Tests-H-Hep B surface Ab One Time Lab Tests-H-Hep B surface Ag Lab Tests-H-Hep C Ab Lab Tests-H-Hepatic Profile Schedule: 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 Format 07/14/2019 Counseling Copay Required:No TelephoneNerbal Order: No Completed by Handout/Tonic Diagnosis Cosign Required: No MD on 07/14/2019 18:11 08/08/2019 00:00 Routine provider Outcome Verbalizes Understanding Generated 07/14/2019 18:11 by MD Bureau of Prisons - NYM Page 3 of 3 EFTA00121320 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 1$: 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 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDO/LIPID Subjective: 66 YR O 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 • EIR GI SIDE EFFECTS. HX OF O iL UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE Y HAS L4 - L5 SEVERE ISIS 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 07/1212019 14:20 by MD Bureau of Prisons - NYM Page 1 of 3 EFTA00121321 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 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 Rhythm (RRR), Normal S1 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 Crania di) l Nerves (CN) Yes: W ASSESSMENT: Constipation, unspecified, K5900 - Current O r 0 20 Motor System-General n Normal Limits Yes: Normal Exam Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current d>er Sleep apnea, G4730 - Current PLAN: New Medication Orders: 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 MethyIPREDNISolone 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 EFTA00121322 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 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 Handout/Topic 07/12/2019 Counseling Diagnosis Copay Required:No Cosign Required: No TelephoneNerbal Order: Completed by n 07/12/2019 14:20 0 Provider Outcome Verbalizes Understanding Generated 07/12f2019 14:20 by MD Bureau of Prisons - NYM Page 3 of 3 EFTA00121323 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 1$: 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 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDO/LIPID Subjective: 66 YR O 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 • EIR GI SIDE EFFECTS. HX OF O iL UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE Y HAS L4 - L5 SEVERE ISIS 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 07/1212019 14:20 by MD Bureau of Prisons - NYM Page 1 of 3 EFTA00121324 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 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 Rhythm (RRR), Normal S1 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 Crania di) l Nerves (CN) Yes: W ASSESSMENT: Constipation, unspecified, K5900 - Current O r 0 20 Motor System-General n Normal Limits Yes: Normal Exam Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current d>er Sleep apnea, G4730 - Current PLAN: New Medication Orders: 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 MethyIPREDNISolone 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 EFTA00121325 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 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 Handout/Topic 07/12/2019 Counseling Diagnosis Copay Required:No Cosign Required: No TelephoneNerbal Order: Completed by n 07/12/2019 14:20 0 Provider Outcome Verbalizes Understanding Generated 07/12f2019 14:20 by MD Bureau of Prisons - NYM Page 3 of 3 EFTA00121326 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: 07/14/2019 17:36 Facility: NYM Amendment made to this note by MD on 07/14/2019 18:11. Bureau of Prisons - NYM EFTA00121327 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race:WHITE Facility: NYM Note Date: 07/12/2019 09:06 Provider: MD Unit: Z05 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: Medication Order Date Prescriber Order Docusate Sodium Capsule 07/12/2019 09:06 TAKE ONE 100 MG CAP Orally - Two Times a Day x 30 day(s) Indication: Constipation, unspecified Discontinued Medication Orders: Exit Medication Order Date Prescriber Order 121757-NYM Bisacodyl E.C. 5 MG TAB 07/12/2019 09:06 Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10 days Discontinue Type: When Pharmacy Processes Discontinue Reason:discontinue Indication: Copay Required:No TelephoneNerbal Order: No Completed by Cosign Required: No MD on 07/12/2019 09:10 Generated 07/1212019 09:10 by MD Bureau of Prisons - NYM Page 1 of 1 EFTA00121328 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race:WHITE Facility: NYM Note Date: 07/07/2019 00:17 Provider: MD Unit: E06 Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MED CL:1 NO CCC APPT. MD Discontinued Laboratory Requests: Details, Freauency The Datg priority Lab Tests-H-Hemoglobin A1C One Time 08/05/2019 00:00 Routine Lab Tests-C-CBC w/diff Lab Tests-L-Lipid Profile Lab Tests-C-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Refiex to Microscopic Additional Information: 66 y/o male, elevated BP Labs requested to be reviewed by: MD New Laboratory Requests: Details, Freauency The Datg priority Chronic Care Clinics-Diabetic-CBC w/diff One Time 07/25/2019 00:00 Routine 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-Comprehensive Metabolic Profile (CMP) New Radiology Request Orders: Details Freauencv End Date Due Date Priority General Radiology-Chest-2 Views One Time 07/25/2019 Routine Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR. Copay Required:No TelephoneNerbal Order: No Completed by Cosign Required: No MD on 07/07/2019 00:30 Generated 07/07/2019 00:30 by MD Bureau of Prisons - NYM Page 1 of 1 EFTA00121329 Bureau of Prisons Health Services Health Screen Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Seizures: Denied Diabetes: Denied Cardiovascular: Denied CVA: Denied Hypertension: Denied Respiratory: Denied Sickle Cell Anemia: Denied Carcinoma/Lymphoma: Denied Allergies: Denied PPD Administration: Date/Time: 07/06/2019 21:39 Provider: PA-C Location: Right Forearm Drug Mfg: Sanofi Pasteur Lot Number: C5474BA Dosage: 0.1mL Route: ID Exp Dt: 10/2020 Comments: Tuberculosis: Hx of Previous Disease: No Blood-tinged Sputum: No Night Sweats: No Weight Loss: No Fever: No Cough: No Comments: Generated 07106/2019 21:56 by PA-C Bureau of Prisons - NYM Page 1 of 6 EFTA00121330 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM 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): 10+ Male Sexual Partners (Last 5 Yrs): 0 Condom Use: Sometimes Sexual 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 HIV History: When Tested: 2019 Test Result: Negative When 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 Generated 07106/2019 21:56 by PA-C Bureau of Prisons - NYM Page 2 of 6 EFTA00121331 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM 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 07106/2019 21:56 by PA-C Bureau of Prisons - NYM Page 3 of 6 EFTA00121332 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM 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: Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/06/2019 21:43 90 Via Machine PA-C Respirations: Date Time Rate Per Minute provider 07/06/2019 21:43 NYM 15 PA-C Blood Pressure: Date Time Value Location position Cuff Size Provider 07/06/2019 21:45 NYM 164/90 Right Arm Sitting Adult-regular PA-C 07/06/2019 21:43 NYM 155/83 Left Arm Sitting Adult-regular PA-C SaO2: Date Time Valuer/O1 Air Provider 07/06/2019 21:43 NYM Height: Date Time Jnches gm provider 07/06/2019 21:43 NYM 72.0 182.9 95 Room Air PA-C PA-C Weight: Dale. Time Jjaa is Waist Circum provider 07/06/2019 21:43 NYM 200.0 90.7 PA-C Prosthetic Devices/Equipment: Denied Potential Items For Follow-up: JIM Travel Outside US Other Infectious Disease History Comments: I have reviewed 0 pages of intake paperworks Generated 07106/2019 21:56 by PA-C Bureau of Prisons - NYM Page 4 of 6 EFTA00121333 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Health Problems Newly Identified During This Encounter: Health Problem Medication Reconciliation. The patient's known medication list including OTC items was compiled and compared to new and changed BOP orders. Reconciled Medications: Source Action Type Rx# Medication OTC No known OTCs Order Detail New Laboratory Requests: Details frequency nue Date priority Lab Tests-H-Hemoglobin A1C One Time 08/05/2019 00:00 Routine Lab Tests-C-CBC w/diff Lab Tests-L-Lipid Profile Lab Tests-C-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic Additional Information: 66 y/o male, elevated BP Labs requested to be reviewed by: MD New Non-Medication Orders: Order Frequency Duration Details Ordered By EKG One Time 66 y/o male PA-C Order Date: 07/06/2019 Fecal Occult Blood One Time 3 different stools PA-C Order Date: 07/06/2019 Schedule: Activity Vision Screen 66 y/o male PPD Reading 07/08/2019 00:00 Nurse Follow-up 07/09/2019 00:00 Mid-Level Provider BP check Date Scheduled Scheduled Provider 07/06/2019 00:00 Optometrist Other: BP noticed to be elevated. IM denies Hx of HTN or any significant chronic medical conditions. He is currently asymptomatic and denies any bodily complaints at this time. Will recheck BP in 2-3 days. Disposition: Follow-up at Sick Call as Needed To be Evaluated by Provider Instructed inmate how to obtain medical, dental, and mental health care. Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Generated 07106/2019 21:56 by PA-C Bureau of Prisons - NYM Page 5 of 6 EFTA00121334 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Completed by PA-C on 07/06/2019 21:56 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 07/06/2019 21:56 by PA-C Bureau of Prisons - NYM Page 6 of 6 EFTA00121335 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: 07/06/2019 21:38 Provider: PA-C Facility: NYM Cosigned with New Encounter Note by MD on 07/07/2019 00:17. Bureau of Prisons - NYM EFTA00121336 Bureau of Prisons Health Services History & Physical 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 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): 10+ Male Sexual Partners (Last 5 Yrs): 0 Condom Use: Sometimes Sexual 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 0710912019 13:03 by MLP Bureau of Prisons - NYM Page 1 of 13 EFTA00121337 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 HIV History: When Tested: 2019 Test Result: Negative When 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 Generated 0710912019 13:03 by MLP Bureau of Prisons - NYM Page 2 of 13 EFTA00121338 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 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: Dental Condition: Denied N/A Generated 0710912019 13:03 by MLP Bureau of Prisons - NYM Page 3 of 13 EFTA00121339 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 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 0710912019 13:03 by MLP Bureau of Prisons - NYM Page 4 of 13 EFTA00121340 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 Immunizations: Hepatitis A and B (TwinRx) 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: 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: Route: 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 07109/2019 13:03 by MLP Bureau of Prisons - NYM Page 5 of 13 EFTA00121341 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 Immunization Date: Provider: MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Varicella 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: Temperature: Date Time Fahrenheit Celsius Location 07/09/2019 12:49 NYM 97.3 36.3 Oral Provider MLP Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/09/2019 12:49 82 Via Machine Regular Respirations: Date Time Rate Per Minute Provider 07/09/2019 12:49 NYM 16 MLP Blood Pressure: Date Time Value Location Position Cuff Size Provider 07/09/2019 12:49 NYM 117/66 Right Arm Sitting Adult-regular SaO2: Date Time vaiue(om Air Provider 07/09/2019 12:49 NYM 97 Room Air MLP Height: Date Time Jnches ran Provider 07/09/2019 12:49 NYM 70.0 177.8 MLP MLP MLP Generated 07109/2019 13:03 by MLP Bureau of Pnsons - NYM Page 6 of 13 EFTA00121342 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 Date Time JncheF ra provider Weight: Date Time un Ea Waist Circum provider 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: Data Ed Yrs Occupation Learns Best By Primary Language Barriers to Education 07/09/2019 12 Banker Speaking/Listening English None 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: Number of Siblings: 1 Significant Illnesses: Comments: Past Hospitalization: Reason Location When Acute Appendicitis Mount Sinai Hospital 1990 Complications: None Comments: Head: Normal: Yes Comments: Generated 0710912019 13:03 by MLP Bureau of Prisons - NYM Page 7 of 13 EFTA00121343 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 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 Fundi 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 OU: Near Vision: OD: OS: OU: OD: OS: OU: 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 0710912019 13:03 by MLP Bureau of Prisons - NYM Page 8 of 13 EFTA00121344 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 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-XII: 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: No Comments: Generated 0710912019 13:03 by MLP Bureau of Prisons - NYM Page 9 of 13 EFTA00121345 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 Rales: No Accessory Muscle Use: No Comments: Spine: Deformity: No Full ROM:Yes Tenderness:No Comments: Cardiovascular: RRR: Yes Normal S1/S2: Yes Murmurs: No Carotid Bruits:No JVD: No Arteries: Eight left Radial: Femoral: Dorsalis Pedis: Post. Tibialis: Comments: Generated 0710912019 13:03 by MLP Bureau of Prisons - NYM Page 10 of 13 EFTA00121346 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 Scaphoid: No Obese: No Gravid: No Hernias: No Bruits: No Masses:No Scars: No Tenderness: No Organomegaly: No Active Bowel Sounds: Yes Comments: Extremities: Nails Clubbing: No Nails Cyanosis: No Lower Extremity Edema • Right: None Lower Extremity Edema • Left: None Atrophy: No Amputations: No Other Deformities: No Varicosities: No Calf Tenderness:No Pulse Deficit: No Strength: Right Left Arm: Leg: Full ROM: Right Left Arm: Yes Yes Leg: Yes Yes Comments: Generated 0710912019 13:03 by MLP Bureau of Prisons - NYM Page 11 of 13 EFTA00121347 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 Left Biceps: Patellar: Brachioradialis: Achilles: Sensation: Vibratory: Yes Light Touch: Yes Pin Prick: Yes Comments: GU: Chaperoned By: Rectum: Not Done Comments: Refused. Male Genitalia: Not Done Comments: Refused. Skin: Normal: Yes Rash: No Redness:No Abnormal Pigmentation: No Abnormal Lesions/Growths: No Comments: Lymphatics: Adenopathy: No Comments: Potential Items For Follow-up: 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 0710912019 13:03 by MLP Bureau of Prisons - NYM Page 12 of 13 EFTA00121348 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 Cleared For Food Services: Yes Health Problems Newly Identified During This Encounter: )-lealth Problem Constipation, unspecified - Current - New Medication Orders: 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 EFTA00121349 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 EFTA00121350 Bureau of Prisons Health Services Vitals All Begin Date: 07/01/2019 Reg #: 76318-054 End Date: 07/24/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Temperature: Date Time Fahrenheit 07/23/2019 06:30 NYM 97.5 Celsius Location 36.4 Oral Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM 97.3 36.3 Orig Entered: 07/09/2019 12:51 EST Pulse: Date Time 07/23/2019 06:30 Orig Entered: 07/09/2019 12:49 Orig Entered: 07/06/2019 21:43 Orig Entered: Rate Per Minute 92 07/23/2019 08:33 EST 82 07/09/2019 12:51 EST 90 07/06/2019 21:48 EST Respirations: Data Time 07/23/2019 06:30 NYM Oral MLP MLP Location Via Machine MLP Via Machine MLP Via Machine PA-C Rate Per Minute Provider Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM Orig Entered: 07/09/2019 12:51 EST 07/06/2019 21:43 NYM Orig Entered: 07/06/2019 21:48 EST Blood Pressure: Data lima Value 07/23/2019 06:30 NYM 140/85 Orig Entered: 07/09/2019 12:49 NYM Orig Entered: 07/06/2019 21:45 NYM Orig Entered: 07/06/2019 21:43 NYM Orig Entered: ocation Right Arm 07/23/2019 08:33 EST 117/66 Right Arm 07/09/2019 12:51 EST 164/90 Right Arm 07/06/2019 21:48 EST 155/83 Left Arm 07/06/2019 21:48 EST SaO2: Date lima 07/23/2019 06:30 NYM 16 Value0/O). Air 96 Room Air Orig Entered: 07/23/2019 08:33 EST • 07/09/2019 12:49 NYM 97 Room Air Orig Entered: 07/09/2019 12:51 EST 16 15 . MLP MLP . MLP MLP PA-C PA-C Position. Sitting Sitting Sitting Sitting MLP MLP PA-C PA-C Provider MLP . MLP Rhythm Provider Regular MLP Regular MLP PA-C Cuff Size Provider Adult-regular MLP MLP PA-C PA-C Adult-regular Adult-regular Adult-regular Provider MLP MLP MLP MLP Generated 07/24/2019 10:37 by FOIA Bureau of Prisons - NYM Page 1 of 2 EFTA00121351 Begin Date: 07/01/2019 End Date: 07/24/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Data Time vakieriot Ail: 07/06/2019 21:43 NYM 95 Room Air Orig Entered: 07/06/2019 21:48 EST • provider PA-C Height: 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 07/06/2019 21:43 NYM 72.0 182.9 PA-C Orig Entered: 07/06/2019 21:48 EST PA-C PA-C Weight: Date Time Lam. Ka Waist Circum provider 07/09/2019 12:49 NYM 194.4 88.2 MLP Orig Entered: 07/09/2019 12:51 EST MLP 07/06/2019 21:43 NYM 200.0 90.7 PA-C Orig Entered: 07/06/2019 21:48 EST PA-C Generated 07/24/2019 10:37 by FOIA Bureau of Prisons - NYM Page 2 of 2 EFTA00121352 Reg #: 76318-054 Admin: Location 07/06/2019 21:39 Right Forearm Orig Entered: 07/06/2019 21:43 EST Total: 1 Bureau of Prisons Health Services PPDs Inmate Name: EPSTEIN, JEFFREY EDWARD Provider PA-C PA-C Reading: Induration Provider 07/09/2019 12:47 0 mm MLP Orig Entered: 07/09/2019 12:47 EST MLP Generated 07/24/2019 10:37 by FOIA Coordinator Bureau of Prisons - NYM Page 1 of 1 EFTA00121353 Bureau of Prisons Health Services Pain Management Begin Date: 07/01/2019 End Date: 07/24/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date Intervention Pain Quality Location Pre Post Provider 07/12/2019 13:25 MEDROL DOSE PACK Shooting Back-Middle 5 Orig Entered: 07/12/2019 13:28 EST MD MD Generated 07124/2019 10:37 by FOIA Coordinator Bureau of Prisons - NYM Page 1 of 1 EFTA00121354 Bureau of Prisons Health Services Allergies Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Allerav No Known Allergies Orig Entered: Total: 1 07/06/2019 21:40 EST Date Noted J2eaction 07/06/2019 PA-C Generated 07/24/2019 10:37 by FOIA Bureau of Prisons - NYM Page 1 of 1 EFTA00121355 Reg #: 76318-054 Bureau of Prisons Health Services Patient Education Assessments & Topics Inmate Name: EPSTEIN, JEFFREY EDWARD Assessment Learns Best By 07/09/2019 Speaking/Listening Total: 1 Primary Language English Orig Entered: 07/09/2019 12:52 EST Date Initiated 07/23/2019 Orig 07/23/2019 Orig 07/14/2019 Orig 07/12/2019 Orig Total: 4 Format Counseling Entered: 07/23/2019 Counseling Entered: 07/23/2019 Counseling Entered: 07/14/2019 Counseling Entered: 07/12/2019 Handout/Topic Access to Care 09:04 EST Plan of Care 09:04 EST Diagnosis 18:11 EST Diagnosis 13:33 EST Assessments Years of Education Barriers To Education 12 None Topics Outcome Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Provider Provider Generated 07124/2019 10:37 by FOIA Coordinator Bureau of Prisons - NYM Page 1 of 1 EFTA00121356 Bureau of Prisons Health Services Health Problems Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Description Axis Code Type Code Diag. Date Status Status Date Current Hyperlipidemia, 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 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 PhD/Chief I DSM-IV No Dx 07/09/2019 Current Psychologist Injury, unspecified 07/23/2019 09:04 EST MLP ICD-10 T1490 07/23/2019 Current RIO self inflicted injuries. Total: 7 Generated 07/24/2019 10:37 by FOIA Coordinator Bureau of Prisons - NYM Page 1 of 1 EFTA00121357 Bureau of Prisons Health Services Vision Screens Reg #: 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. Orig Entered: 07/09/2019 12:54 EST . MLP Generated 07/24/2019 10:37 by FOIA Bureau of Prisons - NYM Page 1 of 1 EFTA00121358 Bureau of Prisons Health Services Immunizations Begin Date: 07/01/2019 Reg #: 76318-054 End Date: 07/24/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Immunization Immunization Date Administered Location Dosage Drug Mfg. Hepatitis A and B (TwinRx) History Unknown Orig Entered: 07/09/2019 12:51 EST Measles/Mumps/Rubella Series Orig Entered: Smallpox Series Orig Entered: Tetanus Orig Entered: Varicella Series Orig Entered: Total: 5 07/09/2019 12:51 EST 07/09/2019 12:51 EST 07/09/2019 12:51 EST 07/09/2019 12:51 EST MLP History Unknown MLP History Unknown MLP History Unknown MLP History Unknown MLP Lot # Exp Date Generated 07/24/2019 10:37 by FOIA Coordinator Bureau of Prisons - NYM Page 1 of 1 EFTA00121359 Bureau of Prisons Heai;ti Services Med[cal Duty Status Reg #: 76318-054 inmate Name: EPSTEIN, JEFFREY EDWARD Housing Status confined to the living quarters e;c: opt _meals pill line _ _ _treatments on complete bed rest: bathroom privileges only _ _ Exp. Date: Exp. Date: X cell: cell on first floor single cell X lower bunk airborne infection isolation Exp. Date: ',ID/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 eq V uipment other: May have the following equipment in his / her possessio Work Restriction I Limitation: Cleared for Food Service: Yes X No Restrictions Comments: N/A Exp. Date: MLP 07/09/2019 Health Services Staff Inmate Name: EPSTEIN, JEFFREY EDWARQ, --r— Reg #: w ALL EXPIRATION DATES ARE AT 24:00 Generated 07124/2019 10:37 by FOIA 76318-054 Date Quarters: H01 Page 1 of 1 O EFTA00121360 Bureau of Prisons Health Services Medication Summary Historical Complex: NYM--NEW YORK MCC Inmate: EPSTEIN, JEFFREY EDWARD Begin Date: 07/01/2019 End Date: 07/24/2019 Reg #: 76318-054 Quarter: H01-001L 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 15 days Docusate Sodium 100 MG Cap Take one capsule (100 MG) by mouth twice daily for 30 days Rx#: 121823-NYM Doctor: Start: 07/12/19 Exp: 08/11/19 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 methylPREDNISolone 4 MG Tab ( 21 count Pack) Take the tablet by mouth as directed Rx#: 121836-NYM Doctor: Start: 07/12/19 Exp: 07/18/19 MD MD MD 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: 60 CAP in 12 days Pharmacy Dispensings: 473 ML in 12 days Pharmacy Dispensings: 21 tab in 12 days Pharmacy Dispensings: 120 Cap in 7 days Generated 07124/2019 10:37 by FOIA Bureau of Prisons - NYM Page 1 of 1 EFTA00121361 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 Asst Unit: Z05 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 07/1912019 13:49 by Dental Bureau of Prisons - NYM Page 1 of 1 EFTA00121362 Bureau of Prisons Psychology Services Suicide Risk Assessment **SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facilit : NYM Date: 07/23/2019 10:09 Provider: PsyD Reg #: 76318-054 Unit Team: 5 Type of Housing: SHU- Administrative Segregation Cell Accommodation: Double-Cell FINDING& This assessment and the resulting recommendations are based on the following sources of information: Clinical Interview, Medical Record, Psychology Data System, Sentry Ramon for Referral The On Call Psychologist, had been contacted by the Operations Lt. at about 2 AM on 7/23/19 to inform her that Mr. Epstein was being placed on Suicide Watch because he was found with a string around his neck. Mr. Epstein was seen by this writer for a Suicide Risk Assessment at about 9:10 AM on 7/23/19. This note is being entered at about 3:35 PM on 7/23/19. Mental Health History According to a Suicide Risk Assessment dated 7/09/19 by , "Inmate Epstein denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time." Self-Harm History According to a Suicide Risk Assessment dated 7/09/19 by , "Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in the past." Substance Abuse History According to a Suicide Risk Assessment dated 7/09/19 by , "Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol." Current Problem Earlier this moming Mr. Epstein was found by SHU staff in his cell with a string loosely tied around his neck. It is unclear at this time if Mr. Epstein had placed the string around his own neck. When Mr. Epstein was asked by this writer how he ended up on Suicide Watch, he denied remembering. He stated he got a drink of water last night in his cell and went back to bed. He said the next thing he remembered is hearing himself snore. He said he wants to know why he is on Suicide Watch. He was informed that staff stated he was found in his cell with a string on his neck. According to Medical records, he had been seen by Medical for this and had a rule out of self inflicted injuries. When this writer reviewed the Staff Suicide Watch Log, it noted that Mr. Epstein told the staff watching him that his cellmate tried to kill him, which Mr. Epstein did not tell this writer when this writer had interviewed Mr. Epstein. This writer was not able to ask Mr. Epstein about this, since Mr. Epstein was now in Legal. The Captain was notified about this notation and the Captain stated they were already aware of this statement. Current Mental Status. Level of Consciousness: Alert and Oriented Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Generated 07/23/2019 15:38 by PsyD Bureau of Prisons - NYM Page 1 of 3 EFTA00121363 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/23/2019 10:09 Provider: PsyD Reg #: 76318-054 Unit Team: 5 Thought Process: Goal Directed Thought Content: Normal Current Mental Status: He exhibited a neutral mood with a full range of affect. His speech was logical and coherent, with no loosening of associations or tangential, circumstantial or irrelevant speech. Auditory and visual hallucinations were denied, and delusions were not elicited. He did not engage in any bizarre or inappropriate behavior. He denied current suicidal or self harm ideation and he agreed to immediately tell staff if he starts to have suicidal or self harm thoughts. He was future oriented. He does not appear to be an immediate danger to self. He denied thoughts of hurting others and he agreed to tell staff if he has these thoughts. RISK AND PROTECTIVE FACTORS ASSESSED: This writer screened the inmate for a variety of empirically validated factors commonly associated with risk for self-harm and suicide. The following STATIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related behaviors: High Profile Crime, Lack of family connections, Sex offender status The following DYNAMIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related behaviors: Current physical pain The following PROTECTIVE factors were assessed to be present and may decrease the inmate's risk of suicide:Able to identify reasons to live, Adequate problem solving skills, Denial of suicidal ideation/intention/plans, Future orientation, View of death as negative, Willingness to engage in treatment Risk Factors: He was found by staff in his cell in SHU with a string loosely tied around his neck, which Mr. Epstein stated he did not remember anything about. It is unclear at this time if Mr. Epstein had placed the string around his own neck or if someone else did. According to Medical, he had a circular line around the base of his neck, which he denied knowing how he obtained. He stated his throat hurts which was reported to Medical. He has a high profile sex offense case and recently was denied bail. When asked if he has any friends or family that are emotionally supportive, he stated he does not know what that means. When emotional supports were explained to him and then again asked if he as any family or friends that are emotionally supportive, he was vague and said he has a lot of people. Protective Factors: He denied current suicidal or self harm thoughts or ever having these thoughts. He denied a history of self harm and suicide attempts. He denied a family history of suicidal and self harm attempts. He denied having any chronic medical conditions. He denied feeling hopeless. He denied a history of childhood abuse. He denied fearing for his safety. He denied feeling like a burden to anyone. He reported he is sleeping adequately. He stated he lives to have fun, to enjoy life, and to learn. He said his future plans include fighting his case and going back to his normal life. Whereas, he is denying suicidal and self harm thoughts and has a lot of protective factors, he is denying that he remembers how he ended up on Suicide Watch and has marks encircling his neck. It is unclear at this time if he had placed the string around his neck or if someone else did. He will remain on Suicide Watch for further observation and safekeeping. DIAGNOSIS• No Diagnosis, No Dx - Current CONCLUSIONS The Overall Acute Suicide Risk for this Inmate is: Moderate Overall Chronic Suicide Risk for this Inmate is: Absent RECOMMENDATION 1. Mr. Epstein will remain on Suicide Watch for further observation and safekeeping. 2. While on Suicide Watch, he will be continuously observed by Inmate Companions. 3. While on Suicide Watch, he will be seen daily by Psychology. 4. Supportive and educative interventions were provided. 5. Medical was informed that he reported his throat hurts. Suicide Watch: A suicide watch was initiated by non-clinical staff and continues to be warranted Suicide Watch was initiated on: 07/23/2019 01:40 Generated 07/23/2019 15:38 by PsyD Bureau of Prisons - NYM Page 2 of 3 EFTA00121364 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/23/2019 10:09 Provider: PsyD Reg #: 76318-054 Unit Team: 5 Completed by PsyD on 07/23/2019 15:38 Generated 07/23/2019 15:38 by PsyD Bureau of Prisons - NYM Page 3 of 3 EFTA00121365 Bureau of Prisons Psychology Services General Administrative Note **SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: 5 Date: 07/23/2019 07:56 Provider: PhD/Chief Comments This On-Call Psychologist was contacted by the Operations Lt. at about 2 AM on 7/23/19 to inform Mr. Epstein was being placed on Suicide Watch because he was found with a string loosely hanging around his neck. Mr. Epstein will be seen today by the duty psychologist for a Suicide Risk Assessment. Completed by PhD/Chief Psychologist on 07/24/2019 07:59 Generated 07/24/2019 07:59 by PhD/Chief Bureau of Prisons - NYM Page 1 of 1 EFTA00121366 Bureau of Prisons Psychology Services SHU Review "SENSITIVE BUT UNCLASSIFIED" Inmate Name: Date of Birth: Date: EPSTEIN, JEFFREY EDWARD 01/20/1953 Sex: M 07/18/2019 07:21 Provider: Facility NYM PhD/Chief Reg #: 76318-054 Unit Team: A&O Placed in SHU: Status: Basis of Review: Mental Status: 07/10/2019 ADMIN.DETENTION Inmate was interviewed No significant mental health issues. Type: Threat to Self: Adjustment: Threat to Others: SHU Low Satisfactory, segregation not detrimental Low Comments Monthly SHU Review Note Inmate Epstein was meeting with his legal team today and has a court hearing. He was not able to be seen for a SHU review. Another attempt to interview him for a SHU review will be done in the near future. Completed by PhD/Chief Psychologist on 07/18/2019 12:06 Generated 07/18/2019 12:06 by PhD/Chief Bureau of Prisons - NYM Page 1 of 1 EFTA00121367 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/16/2019 12:48 Provider: PhD/Chief Reg it 76318-054 Unit Team: A&O Focus of Session Inmate Epstein called for this writer in attorney conference today. The officer in attorney conference notified this writer that he was asking to be seen. Subjective/Objective Presentation Inmate Epstein reported he has not received a spoon or soap in SHU, nor did he receive the phone calls that were "promised to him." He told this writer we need to have mutual trust that his needs are met in the prison. This writer told inmate Epstein that she would address his concerns. On the way out, a staff member told this writer she witnessed inmate Epstein receive two phone calls from the Lt. Nonetheless, this writer informed the SHU lieutenant of his concerns and he said he would ensure that he had soap, a spoon, and his initial SHU phone call. Inmate Epstein did not have any psychological concerns today. He denied any mental health symptoms or suicidality. He has been eating as best as he can and has requested a Kosher diet. Intervention(s) Inmate EPSTEIN was provided with brief supportive and psychoeducation regarding additional coping strategies. Inmate EPSTEIN was receptive to these interventions. He continued with his legal visit. Progress/Plan Inmate EPSTEIN was educated about both routine and emergency procedures for contacting Psychology staff. He was reminded of the self-help books and audiotapes available through the Psychology department. There appears to be no need for follow up at this time. He will be seen in SHU for rounds and monthly SHU reviews. Completed by PhD/Chief Psychologist on 07/18/2019 13:05 Generated 0711B/2019 13:05 by PhD/Chief Bureau of Prisons - NYM Page 1 of 1 EFTA00121368 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/11/2019 15:21 Provider: PhD/Chief Reg #: 76318-054 Unit Team: A&O Focus of Session Inmate Epstein was seen for his psychological observation follow-up in attorney conference this afternoon. Subjective/Objective Presentation Inmate Epstein reported he has been consulting with his attorney most of the day. He elucidated concerns about his incarceration including not receiving his property yet in SHU, feeling cold in his cell, not receiving his Colace, not having enough water in attorney conference, and a desire to recreate in SHU." Inmate Epstein was also upset about wearing an orange jumpsuit and being treated like "a bad guy" when he did not do anything wrong in the prison. Custody and security concerns were addressed with inmate Epstein including why he has to wear his orange jumpsuit (due to his being housed in SHU). He requested that he be placed in a brown uniform during his legal visits. He was told his concerns would be addressed in the SHU meeting. Inmate Epstein stated he is not having any current problems with his cellmate and indicated he at bran cereal for breakfast and took a shower yesterday. He did not sleep well last night. Inmate Epstein continues to deny any suicidal ideation, intention or plan. He did not appear to be in any distress at this time. Intervention(s) Inmate EPSTEIN was provided with brief supportive interventions, CBT-based interventions, and psychoeducation regarding additional coping strategies. Inmate EPSTEIN was receptive to these interventions. Progress/Plan Inmate EPSTEIN was educated about both routine and emergency procedures for contacting Psychology staff. He was reminded of the self-help books and audiotapes available through the Psychology department. He will be seen next week after his bail hearing to assess his mental status and psychological stability. Completed by PhD/Chief Psychologist on 07/12/2019 07:51 Generated 07/12/2019 07:51 by PhD/Chief Bureau of Prisons - NYM Page 1 of 1 EFTA00121369 Bureau of Prisons Psychology Services General Administrative Note **SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/11/2019 14:28 Provider: PsyD Reg #: 76318-054 Unit Team: A&O Comments This writer attempted to see Mr. Epstein in the morning and then again in the afternoon for a Psych Observation Follow Up, but he was in Attorney Conference. Completed by PsyD on 07/11/2019 15:51 Generated 07/11/2019 15:51 by PsyD Bureau of Prisons - NYM Page 1 of 1 EFTA00121370 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/10/2019 08:38 Provider: PhD/Chief Reg #: 76318-054 Unit Team: A&O Focus of Session Inmate Epstein was seen today for a psychological observation contact in the hospital area by this writer. Subjective/Objective Presentation Inmate Epstein appeared well and it was noted in his log book and eating/sleeping chart that he has been eating his meals, sleeping, interacting with the inmate companions, and pacing in his cell. Today, he presented this writer with numerous concerns and requests. He stated he does not want to be housed in the SHU because he is not comfortable there; he wants to be single-celled if he goes to the SHU; he wants Colace, not the Ducolex he received from medical yesterday; he wants to be able to walk around and go to recreation; he does not want to wear an orange uniform to his legal visits because he is treated "like a punished inmate;" he wants a phone call before he leaves the psychological observation area; he wants a shower and towel; he would like to be housed in the cadre (5S) unit; and would like his property, paper, and a pen. Inmate Epstein's concerns were addressed by this writer and it was explained to him he will not be single-celled or placed in a housing unit for safety and security concerns. His medical concerns (constipation) were discussed with health services as well as his desire to be placed on Colace. Inmate Epstein was provided a shower this morning. Intervention(s) Inmate Epstein was provided with supportive intervention and coping skills strategies today. He was receptive to interventions and was able to elucidate his various needs. He did not present with any acute psychopathology and continues to deny any suicidal ideation, intention, or plan. He is looking forward to his bail hearing on Monday but stated he is aware that even if he gets bail, it will take at least two weeks to sort things out so he can leave the jail. Progress/Plan Inmate Epstein is not in any psychological distress, does not present with any mental health symptoms or complaints, and is denying any suicidality. He appears psychologically stable at this time and can be released from the psychological observation area. Inmate Epstein will be housed in the 9S area with a cellmate. He will be seen again tomorrow by psychology to evaluate his mental status and psychological stability. Completed by PhD/Chief Psychologist on 07/10/2019 09:09 Generated 07/10/2019 09:09 by PhD/Chief Bureau of Prisons - NYM Page 1 of 1 EFTA00121371 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Diagnostic and Care Level Formulation Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/09/2019 10:13 Provider: PhD/Chief Reg #: 76318-054 Unit Team: A&O Relevant Historical Information Inmate Epstein is a 66-year-old Caucasian male, currently incarcerated on sex trafficking charges. He denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time. Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in the past. Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol. Presentina Problem/Svmotom Inmate Epstein was seen by this writer for suicide risk assessment today, 7/9/19 at 7:30 a.m. for precautionary reasons. He returned from court yesterday evening. He did not mark any mental health items or symptoms on his Psychology Questionnaire (PSIQ) when he entered the institution. Nonetheless, Inmate Epstein has various risk factors for suicidality including a high profile case with media attention, sex offense/trafficking charges, pre-trial status, and he had a court proceeding yesterday which could have given him bad news regarding his legal situation. Inmate Epstein returned from court after duty hours yesterday evening and staff notified the on-call psychologist. Inmate Epstein was placed on a precautionary psychological observation status until psychology could interview him this morning to conduct a formal suicide risk assessment in order to determine whether he is currently at-risk for suicidality. Diaanostic Formulation. Inmate Epstein has no history of mental health problems and does not exhibit suicidality at this time. He has never received inpatient or outpatient mental health treatment and denied any history of suicidality. Currently, he does not exhibit any acute psychopathology, is currently psychologically stable and is in no psychological distress. As such, he is being classified as a CC1-MH inmate at this time. CARE1-MH is indicative of an inmate who either has no identifiable mental illness (Axis I "No Diagnosis") or is mildly ill and requires clinical intervention on an as-needed basis. Care Level Formulation CARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention. Diagnosis: No Diagnosis, No Dx - Current Completed by PhD/Chief Psychologist on 07/09/2019 10:40 Generated 07/09/2019 10:40 by PhD/Chief Bureau of Prisons - NYM Page 1 of 1 EFTA00121372 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Diagnostic and Care Level Formulation Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/09/2019 10:13 Provider: PhD/Chief Reg #: 76318-054 Unit Team: A&O Relevant Historical Information Inmate Epstein is a 66-year-old Caucasian male, currently incarcerated on sex trafficking charges. He denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time. Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in the ast. Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink Presentina Problem/Svm Inmate Epstein was seen sk assessment today for precautionary reasons. He did not mark any mental health items or symptoms on h ology Questionnaire (PSIQ) when he entered the institution. Nonetheless, Inmate Epstein has various risk factors 'ty including a high profile case with media attention, sex offense/trafficking charges, pre-trial status, and he had proceeding yesterday which could have given him bad news regarding his legal situation. Inmate Epstein return om court er duty hours yesterday evening and staff notified the on-call psychologist. Inmate Epstein was placed on ionary psychological observation status until psychology could interview him this morning to conduct a fo e risk assessment to determine whether he is currently at-risk for suicidality. Diaanostic Formulation Inmate Epstein has no history of mental health proble does not exhibit suicidality at this time. He has never received inpatient or outpatient mental health treatment any history of suicidality. Currently, he does not exhibit any acute psychopathology, is currently psychologi I nd is in no psychological distress. As such, he is being classified as a CC1-MH inmate at this time. CARE1-M e of an inmate who either has no identifiable mental illness (Axis I "No Diagnosis") or is mildly ill and requires ention on an as-needed basis. Care Level Formulation CARE1-MH is indicative of an inmate who shows no significant level of pairment associated with a mental illness and demonstrates no need for regular mental health intervention. Diagnosis: No Diagnosis, No Dx - Current Completed by PhD/Chief Psychologist on 07/09/2019 10:32 Generated 07109/2019 10:32 by PhD/Chief Bureau of Prisons - NYM Page 1 of 1 EFTA00121373 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Diagnostic and Care Level Formulation Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/09/2019 10:13 Provider: PhD/Chief Reg #: 76318-054 Unit Team: A&O Relevant Historical Information Inmate Epstein is a 66-year-old Caucasian male, currently incarcerated on sex trafficking charges. He denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time. Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in the ast. Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink Presentina Problem/Svm Inmate Epstein was seen sk assessment today for precautionary reasons. He did not mark any mental health items or symptoms on h ology Questionnaire (PSIQ) when he entered the institution. Nonetheless, Inmate Epstein has various risk factors 'ty including a high profile case with media attention, sex offense/trafficking charges, pre-trial status, and he had proceeding yesterday which could have given him bad news regarding his legal situation. Inmate Epstein return om court er duty hours yesterday evening and staff notified the on-call psychologist. Inmate Epstein was placed on ionary psychological observation status until psychology could interview him this morning to conduct a fo e risk assessment to determine whether he is currently at-risk for suicidality. Diaanostic Formulation Inmate Epstein has no history of mental health proble does not exhibit suicidality at this time. He has never received inpatient or outpatient mental health treatment any history of suicidality. Currently, he does not exhibit any acute psychopathology, is currently psychologi I nd is in no psychological distress. As such, he is being classified as a CC1-MH inmate at this time. CARE1-M e of an inmate who either has no identifiable mental illness (Axis I "No Diagnosis") or is mildly ill and requires ention on an as-needed basis. Care Level Formulation CARE1-MH is indicative of an inmate who shows no significant level of pairment associated with a mental illness and demonstrates no need for regular mental health intervention. Diagnosis: No Diagnosis, No Dx - Current Completed by PhD/Chief Psychologist on 07/09/2019 10:32 Generated 07109/2019 10:32 by PhD/Chief Bureau of Prisons - NYM Page 1 of 1 EFTA00121374 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: 07/09/2019 10:13 Facility: NYM Amendment made to this note by PhD/Chief Psychologist on 07/09/2019 10:40. Bureau of Prisons - NYM EFTA00121375 Bureau of Prisons Psychology Services Suicide Risk Assessment **SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist Type of Housing: Other Psychological Observation Cell Accommodation: Single Cell FINDINGS This assessment and the resulting recommendations are based on the following sources of information: Medical Record, Clinical Interview Inmate Epstein was placed on psychological observation when he returned from court yesterday evening 7/8/19 for precautionary reasons. He is not on a suicide watch at this time. He was seen this morning for a psychological observation contact and suicide risk assessment this morning, 7/9/19, at 7:30 a.m. as it was determined he possessed some at-risk factors for suicidality. Reason for Referral Inmate Epstein is being seen for suicide risk assessment today for precautionary reasons. Inmate Epstein has various risk factors for suicidality at this time including a high profile case with media attention, sex offense/trafficking charges, pre-trial status, and he had a court proceeding yesterday which could have given him bad news regarding his legal situation. As such, this writer instructed R&D staff, as well as the Lieutenant's Office, to immediately notify the psychology department when he returned from court. Inmate Epstein returned from court after duty hours and denied suicidality. The aforementioned staff notified the on-call psychologist and inmate Epstein was placed on a precautionary psychological observation status until psychology could interview him this morning to conduct a suicide risk assessment. Developmental History Inmate Epstein denied any history of being the victim and/or perpetrator of physical or sexual abuse. Educational History/Cognitive Impairment Inmate Epstein reported he obtained his high school diploma and attended some graduate classes in the area of mathematics. Arrest History and Experience of Incarceration Inmate Epstein reported he has served time in Palm Beach County jail on sex offense charges (soliciting prostitution) in the past. He is now being charged with sex trafficking, on a federal level. Mental Health History Inmate Epstein denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time. Self-Harm History Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in the past. Substance Abuse History Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol. Medical Concern% Inmate Epstein denied any significant medical problems, other than a history of high triglycerides. He reported feeling constipated at this time. Current Problem Inmate Epstein is currently on psychological observation due to his having multiple risk factors associated with suicidality. He denies any suicidality at this time and has no mental health or suicide history. He is being seen for a suicide risk assessment in an abundance of caution. Current Mental Statga Generated 07110/2019 09:20 by PhD/Chief Bureau of Prisons - NYM Page 1 of 3 EFTA00121376 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist 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 Inmate Epstein did not exhibit any acute psychopathology and exhibited a clear mental status. Current Mental Status: Mr. EPSTEIN was alert and oriented. He was polite, calm, and cooperative in demeanor. He exhibited a neutral affect with appropriate range. Eye contact and hygiene were appropriate. The inmate spoke with normal rate, tone, and volume. His thoughts were organized and coherent, with no loosening of associations or tangential, circumstantial, or irrelevant content. There was no evidence of perceptual disturbance, delusional ideation, or a formal thought disorder. He did not engage in any bizarre or inappropriate behavior. He noted having normal sleeping and eating habits. Mr. EPSTEIN explicitly denied recent and current suicidal ideation, planning, and intent. He was future-oriented and expressed a commitment to life and safety, agreeing to contact staff immediately should he experience suicidal ideation. RISK AND PROTECTIVE FACTORS ASSESSED: This writer screened the inmate for a variety of empirically validated factors commonly associated with risk for self-harm and suicide. The following STATIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related behaviors: Sex offender status, Lack of family connections, High Profile Crime Of the DYNAMIC risk factors assessed, none were found to be present. The following PROTECTIVE factors were assessed to be present and may decrease the inmate's risk of suicide:Willingness to engage in treatment, View of death as negative, Future orientation, Denial of suicidal ideationnntention/plans, Adequate problem solving skills, Able to identify reasons to live As noted above, Inmate Epstein is a 66-year-old Caucasian male. He has various risk factors for suicidality at this time including a high profile case with extensive media attention, sex offense/trafficking charges, pre-trial status, and he had a court proceeding yesterday which may have given him bad news regarding his legal situation. Inmate Epstein also informed this writer that his only family at this time is his brother, with whom he does not have a close relationship with. Despite these risk factors, inmate Epstein possesses a number of protective factors at this time. Inmate Epstein adamantly denied any suicidal ideation, intention or plan. He was very future oriented and requested a phone call, to meet with his attorney, to take a shower, and to brush his teeth. He was eating his cereal when this writer arrived and said "I have my paper spoon here." He reported he is going to have a bail hearing on Monday and believes he is going to be released from jail. Inmate Epstein reported he is a Banker and has a "big business" in the community and that "being alive is fun." He also revealed he enjoys learning and teaching. He has confidence in his attorney and described him as "competent." Inmate Epstein denied any mental health history or history of suicidality. He also reported none of his family members have mental health histories. Inmate Epstein stated he is a mathematician and took post graduate classes in this area of study. Inmate Epstein stated he has a support system in the community, including friends and other associates. Finally, inmate Epstein demonstrated a good sense of humor and did not appear dysphoric, agitated or anxious. No acute psychopathology was noted. Overall, inmate Epstein has numerous protective factors at this time that outweigh his risk factors for suicidality. He has a positive outlook regarding his legal case, demonstrates no psychiatric symptoms, has no psychiatric or suicide history, and verbalized a desire to be alive at this time and future orientation. DIAGNOSIS• No Diagnosis, No Dx - Current Generated 07110/2019 09:20 by PhD/Chief Bureau of Prisons - NYM Page 2 of 3 EFTA00121377 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist CONCLUSION The Overall Acute Suicide Risk for this Inmate is: Low Overall Chronic Suicide Risk for this Inmate is: Absent ftECOMMENDATION Inmate Epstein is currently on psychological observation pending suitable housing placement. In light of his current sex offense charges and extensive media coverage on the television, he will need to be confined in a suitable housing unit. Inmate Epstein will be seen daily while on psychological observation and will be seen for a psychological observation follow-up session once he is released from observation. Inmate Epstein denied the need for psychological intervention, self-help materials, or follow-up. He has been classified as a CC1-MH inmate at this time. CARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention. Suicide Watch: A suicide watch is not warranted at this time Completed by PhD/Chief Psychologist on 07/10/2019 09:20 Generated 07110/2019 09:20 by PhD/Chief Bureau of Prisons - NYM Page 3 of 3 EFTA00121378 Bureau of Prisons Psychology Services Suicide Risk Assessment **SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist Type of Housing: Other Psychological Observation Cell Accommodation: Single Cell FINDING& This assessment and the resulting recommendations are based on the following sources of information: Clinical Interview, Medical Record Inmate Epstein was placed on s chological observation when he returned from court yesterday evening 7/8/19 for precautionary reasons. He i a suicide watch at this time. Reason for Referral Inmate Epstein is being seen t de risk assessment today for precautionary reasons. Inmate Epstein has various risk factors for suicidality at this ing a high profile case with media attention, sex offense/trafficking charges, pre-trial status, and he had a court ing yesterday which could have given him bad news regarding his legal situation. As such, this writer instruc &D staff s well as the Lieutenant's Office, to immediately notify the psychology department when he returned fr Inmate Epstein returned from court after duty hours and denied suicidality. The aforementioned staff noti t -call psychologist and inmate Epstein was placed on a precautionary psychological observation status until psycholo nterview him this morning to conduct a suicide risk assessment. Developmental History Inmate Epstein denied any history of being the victim nt p_pr etrator of physical or sexual abuse. Educational History/Cognitive Impairment Inmate Epstein reported he obtained his high school diplom ed some graduate classes in the area of mathematics. Arrest History and Experience of Incarceration Inmate Epstein reported he has served time in Palm Beach County jail nse charges (soliciting prostitution) in the past. He is now being charged with sex trafficking, on a federal level. Mental Health History Inmate Epstein denied any history of mental health treatment, either on an inpati ient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also d t y~acute mental health symptoms at this time. Self-Harm History Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied eve e ging in any suicide attempts or self-injurious behavior in the past. Substance Abuse History Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol. Medical Concerns. Inmate Epstein denied any significant medical problems, other than a history of high triglycerides. He reported feeling constipated at this time. Current Problem Inmate Epstein is currently on psychological observation due to his having multiple risk factors associated with suicidality. He denies any suicidality at this time and has no mental health or suicide history. He is being seen for a suicide risk assessment in an abundance of caution. Current Mental Status Level of Consciousness: Alert and Oriented Generated 07/0912019 10:36 by PhD/Chief Bureau of Prisons - NYM Page 1 of 3 EFTA00121379 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Date: 07/09/2019 08:41 Provider: Reg #: 76318-054 Facility: NYM Unit Team: A&O PhD/Chief Psychologist Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Inmate Epstein did not exhibit any acute psychopathology and exhibited a clear mental status. Current Mental Status: Mr. EP a neutral affect with appropli and volume. His thoughts irrelevant content. There not engage in any bizarre or ina explicitly denied recent and curve commitment to life and safety, agree IN was alert and oriented. He was polite, calm, and cooperative in demeanor. He exhibited e. Eye contact and hygiene were appropriate. The inmate spoke with normal rate, tone, nized and coherent, with no loosening of associations or tangential, circumstantial, or nce of perceptual disturbance, delusional ideation, or a formal thought disorder. He did e behavior. He noted having normal sleeping and eating habits. Mr. EPSTEIN 'deation, planning, and intent. He was future-oriented and expressed a act staff immediately should he experience suicidal ideation. RISK AND PROTECTIVE FACTORS SSED. This writer screened the inmate for a variety o y validated factors commonly associated with risk for self-harm and suicide. The following STATIC risk factors were assessed t and increase the inmate's risk for engaging in suicide related behaviors: High Profile Crime, Lack of family connect s, ender status Of the DYNAMIC risk factors assessed, none were foun o r ent. The following PROTECTIVE factors were assessed to be pres may decrease the inmate's risk of suicide:Able to identify reasons to live, Adequate problem solving skills, Denial of suici 'ntention/plans, Future orientation, View of death as negative, Willingness to engage in treatment As noted above, Inmate Epstein is a 66-year-old Caucasian male. He k factors for suicidality at this time including a high profile case with extensive media attention, sex offense/t arges, pre-trial status, and he had a court proceeding yesterday which may have given him bad news regarding his leg Inmate Epstein also informed this writer that his only family at this time is his brother, with whom he does not hav cl ationship with. Despite these risk factors, inmate Epstein possesses a number of protective factors afi Inmate Epstein adamantly denied any suicidal ideation, intention or plan. He was very future oriented and requeste a n call, to meet with his attorney, to take a shower, and to brush his teeth. He was eating his cereal when this writ d said "I have my paper spoon here." He reported he is going to have a bail hearing on Monday and believes he is g t sed from jail. Inmate Epstein reported he is a Banker and has a "big business" in the community and that "bei li fun." He also revealed he enjoys learning and teaching. He has confidence in his attorney and described him as mpetent." Inmate Epstein denied any mental health history or history of suicidality. He also reported none of his family members have mental health histories. Inmate Epstein stated he is a mathematician and took post graduate classes in this area of study. Inmate Epstein stated he has a support system in the community, including friends and other associates. Finally, inmate Epstein demonstrated a good sense of humor and did not appear dysphoric, agitated or anxious. No acute psychopathology was noted. Overall, inmate Epstein has numerous protective factors at this time that outweigh his risk factors for suicidality. He has a positive outlook regarding his legal case, demonstrates no psychiatric symptoms, has no psychiatric or suicide history, and verbalized a desire to be alive at this time and future orientation. DIAGNOSIS. No Diagnosis, No Dx - Current CONCLUSIONS The Overall Acute Suicide Risk for this Inmate is: Low Overall Chronic Suicide Risk for this Inmate is: Absent Generated 0710912019 10:36 by PhD/Chief Bureau of Prisons - NYM Page 2 of 3 EFTA00121380 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist ftECOMMENIIATION Inmate Epstein is currently on psychological observation pending suitable housing placement. In light of his current sex offense charges and extensive media coverage on the television, he will need to be confined in a suitable housing unit. Inmate Epstein will be seen daily while on psychological observation and will be seen for a psychological observation follow-up session once he is released from observation. Inmate Epstein denied the need for psychological intervention, self-help materials, or follow-up. He has been classified as a CC1-MH inmate at this time. CARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention. Suicide Watch: A suicide watch is not warranted at this time Completed by PhD/Chief Psychologist on 07/09/2019 10:36 Generated 0710912019 10:36 by PhD/Chief Bureau of Prisons - NYM Page 3 of 3 EFTA00121381 Bureau of Prisons Psychology Services Suicide Risk Assessment **SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist Type of Housing: Other Psychological Observation Cell Accommodation: Single Cell FINDING& This assessment and the resulting recommendations are based on the following sources of information: Clinical Interview, Medical Record Inmate Epstein was placed on s chological observation when he returned from court yesterday evening 7/8/19 for precautionary reasons. He i a suicide watch at this time. Reason for Referral Inmate Epstein is being seen t de risk assessment today for precautionary reasons. Inmate Epstein has various risk factors for suicidality at this ing a high profile case with media attention, sex offense/trafficking charges, pre-trial status, and he had a court ing yesterday which could have given him bad news regarding his legal situation. As such, this writer instruc &D staff s well as the Lieutenant's Office, to immediately notify the psychology department when he returned fr Inmate Epstein returned from court after duty hours and denied suicidality. The aforementioned staff noti t -call psychologist and inmate Epstein was placed on a precautionary psychological observation status until psycholo nterview him this morning to conduct a suicide risk assessment. Developmental History Inmate Epstein denied any history of being the victim nt p_pr etrator of physical or sexual abuse. Educational History/Cognitive Impairment Inmate Epstein reported he obtained his high school diplom ed some graduate classes in the area of mathematics. Arrest History and Experience of Incarceration Inmate Epstein reported he has served time in Palm Beach County jail nse charges (soliciting prostitution) in the past. He is now being charged with sex trafficking, on a federal level. Mental Health History Inmate Epstein denied any history of mental health treatment, either on an inpati ient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also d t y~acute mental health symptoms at this time. Self-Harm History Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied eve e ging in any suicide attempts or self-injurious behavior in the past. Substance Abuse History Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol. Medical Concerns. Inmate Epstein denied any significant medical problems, other than a history of high triglycerides. He reported feeling constipated at this time. Current Problem Inmate Epstein is currently on psychological observation due to his having multiple risk factors associated with suicidality. He denies any suicidality at this time and has no mental health or suicide history. He is being seen for a suicide risk assessment in an abundance of caution. Current Mental Status Level of Consciousness: Alert and Oriented Generated 07/0912019 10:36 by PhD/Chief Bureau of Prisons - NYM Page 1 of 3 EFTA00121382 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Date: 07/09/2019 08:41 Provider: Reg #: 76318-054 Facility: NYM Unit Team: A&O PhD/Chief Psychologist Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Inmate Epstein did not exhibit any acute psychopathology and exhibited a clear mental status. Current Mental Status: Mr. EP a neutral affect with appropli and volume. His thoughts irrelevant content. There not engage in any bizarre or ina explicitly denied recent and curve commitment to life and safety, agree IN was alert and oriented. He was polite, calm, and cooperative in demeanor. He exhibited e. Eye contact and hygiene were appropriate. The inmate spoke with normal rate, tone, nized and coherent, with no loosening of associations or tangential, circumstantial, or nce of perceptual disturbance, delusional ideation, or a formal thought disorder. He did e behavior. He noted having normal sleeping and eating habits. Mr. EPSTEIN 'deation, planning, and intent. He was future-oriented and expressed a act staff immediately should he experience suicidal ideation. RISK AND PROTECTIVE FACTORS SSED. This writer screened the inmate for a variety o y validated factors commonly associated with risk for self-harm and suicide. The following STATIC risk factors were assessed t and increase the inmate's risk for engaging in suicide related behaviors: High Profile Crime, Lack of family connect s, ender status Of the DYNAMIC risk factors assessed, none were foun o r ent. The following PROTECTIVE factors were assessed to be pres may decrease the inmate's risk of suicide:Able to identify reasons to live, Adequate problem solving skills, Denial of suici 'ntention/plans, Future orientation, View of death as negative, Willingness to engage in treatment As noted above, Inmate Epstein is a 66-year-old Caucasian male. He k factors for suicidality at this time including a high profile case with extensive media attention, sex offense/t arges, pre-trial status, and he had a court proceeding yesterday which may have given him bad news regarding his leg Inmate Epstein also informed this writer that his only family at this time is his brother, with whom he does not hav cl ationship with. Despite these risk factors, inmate Epstein possesses a number of protective factors afi Inmate Epstein adamantly denied any suicidal ideation, intention or plan. He was very future oriented and requeste a n call, to meet with his attorney, to take a shower, and to brush his teeth. He was eating his cereal when this writ d said "I have my paper spoon here." He reported he is going to have a bail hearing on Monday and believes he is g t sed from jail. Inmate Epstein reported he is a Banker and has a "big business" in the community and that "bei li fun." He also revealed he enjoys learning and teaching. He has confidence in his attorney and described him as mpetent." Inmate Epstein denied any mental health history or history of suicidality. He also reported none of his family members have mental health histories. Inmate Epstein stated he is a mathematician and took post graduate classes in this area of study. Inmate Epstein stated he has a support system in the community, including friends and other associates. Finally, inmate Epstein demonstrated a good sense of humor and did not appear dysphoric, agitated or anxious. No acute psychopathology was noted. Overall, inmate Epstein has numerous protective factors at this time that outweigh his risk factors for suicidality. He has a positive outlook regarding his legal case, demonstrates no psychiatric symptoms, has no psychiatric or suicide history, and verbalized a desire to be alive at this time and future orientation. DIAGNOSIS. No Diagnosis, No Dx - Current CONCLUSIONS The Overall Acute Suicide Risk for this Inmate is: Low Overall Chronic Suicide Risk for this Inmate is: Absent Generated 0710912019 10:36 by PhD/Chief Bureau of Prisons - NYM Page 2 of 3 EFTA00121383 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist ftECOMMENIIATION Inmate Epstein is currently on psychological observation pending suitable housing placement. In light of his current sex offense charges and extensive media coverage on the television, he will need to be confined in a suitable housing unit. Inmate Epstein will be seen daily while on psychological observation and will be seen for a psychological observation follow-up session once he is released from observation. Inmate Epstein denied the need for psychological intervention, self-help materials, or follow-up. He has been classified as a CC1-MH inmate at this time. CARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention. Suicide Watch: A suicide watch is not warranted at this time Completed by PhD/Chief Psychologist on 07/09/2019 10:36 Generated 0710912019 10:36 by PhD/Chief Bureau of Prisons - NYM Page 3 of 3 EFTA00121384 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: 07/09/2019 08:41 Facility: NYM Amendment made to this note by PhD/Chief Psychologist on 07/10/2019 09:20. Bureau of Prisons - NYM EFTA00121385 Bureau of Prisons Psychology Services General Administrative Note **SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/08/2019 10:41 Provider: PhD/Chief Reg it 76318-054 Unit Team: A&O Comments This writer consulted with Dr. Robert Nagle, Central Office, regarding inmate Epstein. Inmate Epstein has various risk factors for suicidality including a high profile case with media attention, sex offense charges, pre-trial status, and a court proceeding today which could potentially be giving him bad news regarding his legal situation. As such, when inmate Epstein returns from court, R&D staff as well as Lieutenant's have been informed to immediately notify the psychology department. If he returns after duty hours, the aforementioned staff were instructed to notify the on-call psychologist and to place inmate Epstein on a watch status until psychology can conduct a thorough suicide risk assessment. Completed by PhD/Chief Psychologist on 07/08/2019 10:49 Generated 07/08f2019 10:49 by PhD/Chief Bureau of Prisons - NYM Page 1 of 1 EFTA00121386 Bureau of Prisons Psychology Services Risk of Sexual Abusiveness **SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/08/2019 09:35 Provider: . PsyD/PhD Reg #: 76318-054 Unit Team: A&O Comments Risk of Sexual Abusiveness During the intake screening process, for Inmate Epstein, based on the documentation available at the time of the screening, and Inmate Epstein's self-report, he was identified as being at risk for sexual abusiveness due to previous perpetration of sexual abuse in the community or in an institutional setting, as evidenced by the following objective criteria: ( ) Having a history of prior institutional violence or sexual abuse perpetration (X ) Having a history of prior sexual abuse perpetration in the community (X ) Having prior convictions of violent offenses As required by P5324.11, Sexually Abusive Behavior Prevention and Intervention, Inmate Epstein was seen by Psychology on today's date to assess his risk factors for sexual abusiveness. At the onset of this clinical contact, the inmate was informed about the BOP requirements regarding PREA. Inmate Epstein indicated he understands the institution's policy against engaging in sexual behavior. His risk factors for sexual abusiveness were assessed and include: ( ) History of prior sexual victimization in prison ( X ) History of prior prison sexual predation ( ) History of head injury with loss of consciousness ( ) History of childhood psychological, physical, sexual abuse ( ) Witnessed family violence ( ) Antisocial Personality Disorder traits of irritability/aggressiveness and recklessness ( ) Hypersexuality (defined by eight or more orgasms a week prior to prison) ( ) Hypermasculinity ( ) Other: Based on this clinical assessment, the inmate is considered to be at: (X ) Low Risk of Abusiveness at this facility (Note: Even though this inmate is judged to be at low risk of sexual abusiveness, an unforeseen change in risk factors may significantly alter his risk level.). Programming recommendations included sex offender treatment. Inmate Epstein declined programming recommendations.The inmate understands the procedure for contacting Psychology for routine or emergent services. ( ) Moderate Risk of Abusiveness. The Unit Team and Correctional Staff have been notified regarding Psychology staffs recommendation that he not be housed in a cell with any inmates identified as at increased risk for sexual victimization. Psychology also recommends a greater level of supervision regarding his work and education assignments. Programming recommendations include XXXXX. Inmate =inmateLastName is agreeable to/ declined programming recommendations. ( ) High Risk of Abusiveness. It is recommended this inmate be housed in the Special Housing Unit in accordance with P5324.11 to "keep separate those inmates at high risk of being sexually victimized from those at high risk of being sexually abusive" until Correctional Services and Correctional Programs staff can assess his appropriateness for general population at this facility. This inmate should not be housed with any inmates judged to be at an increased risk for sexual victimization. Programming recommendations include XXXXX. Inmate =inmateLastName is agreeable to/ declined programming recommendations. Generated 07/0B/2019 09:41 by PsyD/PhD Bureau of Prisons - NYM Page 1 of 2 EFTA00121387 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/08/2019 09:35 Provider: PsyD/PhD Reg #: 76318-054 Unit Team: A&O Completed by PsyD/PhD on 07/08/2019 09:41 Generated 07/08/2019 09.41 by PsyD/PhD Bureau of Prisons - NYM Page 2 of 2 EFTA00121388 Bureau of Prisons Psychology Services Intake Screening **SENSITIVE BUT UNCLASSIFIED** Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facili : NYM Date: 07/08/2019 09:24 Provider: . PsyD/PhD Reg #: 76318-054 Unit Team: A&O Limits of Confidentiality Limits of confidentiality were reviewed with inmate EPSTEIN. He expressed an understanding of the limits of confidentiality and consented to be interviewed accordingly. Data Source(s) The following data sources were reviewed in conjunction with this Initial Intake Evaluation: Self-Report, SENTRY, Staff Observation. Inmate Epstein is a 66-year-old, Black male who was seen by Psychology Services due to newly arriving at MCC-NY. He denied a history of mental health treatment on his Psychology Services Intake Questionnaire. Mental Health History and Current Symptoms No history of mental health issues was noted. No history of prior mental health treatment was noted. No current mental health symptoms were noted. No suicidal ideation, attempts, or self-harm were noted. Substance Abuse No history of substance abuse was noted. No history of substance abuse treatment was noted. Sex Offenses No sexual offense convictions were noted. No history of sexual predation in a correctional setting was noted. Relevant Psychosocial History Noteworthy psychosocial issues: Other. Inmate Epstein is currently incarcerated for a Sex Trafficking. He stated he was previously incarcerated three months for prostitution. Inmate Epstein stated he is single and does not have any children. He revealed he was living in New York. He stated he completed high school. He stated he was employed in banking work prior to his incarceration. Adjustment to Incarceration Adjustment to incarceration concerns were identified: Other. SEXUAL ABUSE HISTORY Inmate Epstein denied being the victim of physical or sexual abuse. He is currently charged with sex trafficking and has previously been charged with prostitution. He was informed of the programs offered by MCC-NY as well as the Bureau of Prisons. Additionally, he was informed of this institutions self-help program. Inmate Epstein reported he was not currently interested in any treatment programs. MENTAL STATUS: Inmate Epstein appeared calm, controlled, without signs of psychomotor agitation or retardation. He was fully cooperative, maintained good eye-contact, and related in an interpersonally appropriate manner with interviewer. Speech and thought processes were organized, coherent, logical, and goal-directed. Based on informal assessment during this interview, this inmate's cognitive functioning appeared within normal limits, as reflected by adequate long and short-term memory, good attention, and appropriate concentration during interview, as well as adequate receptive and expressive language skills. Inmate denied any current sleep disturbances and described his appetite as adequate. This inmate denied recent or present morbid thoughts, passive or active suicidal ideation, intent or plan and contracted for safety. This inmate's verbalizations were optimistic, future oriented, and without indications of helpless or hopeless thinking. Inmate denied any familial history of suicide behaviors or attempts. This inmate was provided with supportive psychotherapy, and psycho-education to strengthen coping skills and facilitate adjustment to incarceration. Findings Care Level: CARE1-MH Generated 07/08/2019 09:30 by PsylD/PhD Bureau of Prisons - NYM Page 1 of 2 EFTA00121389 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Date: 07/08/2019 09:24 Provider: Reg #: 76318-054 Facility: NYM Unit Team: A&O . PsyD/PhD Inmate EPSTEIN denied any history of mental health symptoms or treatment. He denied any current mental health symptoms. He does not meet criteria for any current psychological diagnosis. He meets criteria for Mental Health Care Code 1. CARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention. Recommendations The following psychological services are recommended: Other. Inmate EPSTEIN was educated about both routine and emergency procedures for contacting Psychology staff. He does not appear to be in distress at this time. He agreed to contact psychology if he feels he needs psychology services in the future. He meets criteria for CC1 and does not require scheduled follow up at this time. Completed by PsyD/PhD on 07/08/2019 09:30 Generated 07/08/2019 09:30 by PsyD/PhD Bureau of Prisons - NYM Page 2 of 2 EFTA00121390 Federal Bureau of Prisons U.S. Medical Center for Federal Prisons 1900 W. Sunshine Street Sprin field• MO 65807 *** 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 mUminf1.73 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 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/Great Ratio 16.1 5.0-30.0 Cholesterol H 216 <200 mg/dL Triglycerides H 413 10-150 mg/dL Calculation of 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 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 fL MCH 28.8 27.1-34.9 Pg MCHC L 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 A! =Abnormal Critical Page 1 of 3 EFTA00121391 Federal Bureau of Prisons U.S. Medical Center for Federal Prisons 1900 W. Sunshine Street Sprin field• MO 65807 *** 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 HEMATOLOGY 1 MPV 10.4 6.9-10.5 f. Neutrophils 58.7 Therapeutic decision making should be based on absolute values, rather than percentages Lymphocytes % 25.0 Monocytes °A) 11.1 Eosinophils % 4.1 Basophils % 0.8 Immature Granulocytes 0.3 0.0-5.0 °A. °A. 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 Eosinophils # 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 MC 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 EFTA00121392 Fcdcral Bureau of Prisons U.S. Medical Center for Federal Prisons 1900 W. Sunshine Street Sprin field• MO 65807 **" 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=I-ligh H!=High Critical A=Abnormal A! =Abnormal Critical Page 3 of 3 EFTA00121393 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 07/14/2019 18:12. Bureau of Prisons - NYM EFTA00121394 BP-5358.060 SEP 05 MEDICAL TREATMENT REFUSAL CDFRM U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-10-2019 Date 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) 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 Patien Signature S —re of Lness Date NYM-NEW YORK MCC Date EFTA00121395