EFTA00134682.pdf

Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/09/2019 12:35 Provider: Race: WHITE Reg 4: 76, Facility: Unit: HO 18-054 Thorax: Contour Normal:Yes Increased AP Diameter: No Asymmetrical Expansion:No Lungs Clear: Yes Wheezes: No Crackles: No Rhonchl: No Rates: No Accessory Muscle Use: No Comments: Spine: Deformity: No Full ROM:Yes Tondornoss:No Comments: Cardiovascular: RRR: Yes Normal S1/S2: Yos Murmurs: No Carotid Bruits:No JVD: No Arteries: Right Left Radial: Femoral: Dorsalis Podis: Post. TIblalls: Comments: Generated 07/09/2019 13:03 by Bureau of Prisons • NYM Page 10 of 13 SDNY_C0003938 EFTA_00000 147 EFTA00134682 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 7 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: Encounter Date: 07/09/2019 12:35 Provider: Unit 18454 1 Abdomen: Normal Contour:Yes Scaphoid: No Obese: No Gravid: No Hernias: No Bruits: No Masses:No Scars: No Tenderness: No Organomogaly: No Active Bowel Sounds: Yes Comments: Extremities: Nails Clubbing: No Nails Cyanosis: No Lower Extremity Edema - Right: None Lower Extremity Edema - Left: None Atrophy: No Amputations: No Other Deformities: No Varicosities:No Calf Tenderness: No Pulse Deficit: No Strength: Plight Soft Arm: Log: Full ROM: Right LA Arm: Yes Yes Leg: Yes Yes Comments: Generated 07109/2019 13:03 by Buntou of Prisons Page 11 of 13 SbNY_00000939 EFTA_00000148 EFTA00134683 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg ft 78-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: Encounter Date: 07/09/2019 12:35 Provider. Unit: 1 Reflexes: Bight knit 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 LosIons/Growths: No Comments: Lymphatics: Adenopathy: No Comments: Potential Items For Follow-up: ISM Travel Outside US Other Infectious Disease History Rectum Not Done Male Genitalia Not Done PPD Administration Not Performed Comments: Patient has a history of constipation. Generated 07/09/2019 13:03 by Bureau of Prisms - NY M Psg. 12 of 13 DNY_00000940 EFTA_00000149 EFTA00134684 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Facility: NYM Date: 07/09/2019 12:35 Provider. itHITE Unit: H01 Cleared For Food Services: Yes Health Problems Newly Identified During This Encounter: Health Problem Constipation, unspecified - Current - Now Medication Orders: Medication Bisacodyl E.C. Tablet Indication: Constipation, unspecified Disposition: Follow-up at Sick Call as Needed Order Date halAdbladli 07/09/2019 12:35 5 mg Only at bedtime PFtN x10 day(s) Instructed inmate how to obtain medical, dental, and mental health care. Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Completed by on 07/09/2019 13:03 Requested to be cosigned by Cosign documentation will be displayed on the following page. Generated 07/09/2019 13:03 by Bureau of Prisons • NYM Paps 13 of 13 SONY 00000941 - EFTA_000001 50 EFTA00134685 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: Date of Birth: 01/20/1953 Sex: M Race: Encounter Date: 07/09/2019 12:35 Provider: Facility: 76318-054 WHITE NYM Cosigned by on 07/11/2019 22:41. Bureau of Prisons - NYM SDNY_00000942 EFFA_00000 1 5 1 EFTA00134686 Bureau of Prisons Health Services Inmate Local Hospital Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD SENSITIVE BUT UNCLASSIFIED — This information Is confidential and must be appropriately safeguarded. Transfer To: Transfer Date: 08/10/2019 Health Problems Health Problem Hyperripldemia, unspecified HYPERTRIGLYCERIDEMIA Sleep apnea Essential (primary) hypertension BY HX. Constipation, unspecified Low back pain Neuralgia and neuritis, unspecified No Diagnosis Prediabetes Injury, unspecified R./O self Inflicted injuries. Body mass index (BMI) 27.0-27.9, adult ate= Current Current Current Current Current Current Current Current Current Current Medications: All medications to be continued until evaluated by a physician unless otherwise In Bolded drugs required for transport. Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take one capsule (100 MG) by mouth twice Docusate Sodium 100 MG Cap Exp: 01/22/2020 SIG: Take one capsule (100 MG) twice daily by of water Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML Exp: 10/28/2019 SIG: shake well take 10ml by daily AS NEEDED Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by OTCs: Listing of all known OTCs this inmate is currently taking. None Pending Appointments icated. ily for 30 days th with plenty th twice uth with food Date Time Activity Provider Clinical Encounter Optometrist 07/24/2019 00:00 01/07/2020 00:00 Chronic Care Visit Mid-Level Provider 07/01/2020 00:00 Chronic Care Visit Physician 01 07/09/2020 00:00 PPD Administration Nurse Pending Non-Medication Orders: Order Order Date Freouency EKG 07/06/2019 One Time Focal Occult Blood 07/06/2019 One Time TB Clearance: Yes Last PPD Date: 07/09/2019 Last Chest X-Ray Date: TB Treatment TB Follow-up Recommended: No Sickle Cell: Sickle Cell Trait/Disease: No Duration Petah 66 y/o male 3 different stools Induration: 0mm Results: Sx free for 30 days: Yes Generated 08/1 0/2019 07:00 by RN Bureau of Prisons - NYM I Re 1 el 2 S NY 00000903 EIFIA_00000152 EFTA00134687 Reg 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD SENSITIVE BUT UNCLASSIFIED — This Won-nation Is confidential and must be appropriately safeguard d. Limitations:Restrictions/Diets: Cell: lower bunk — 10/09/2019 Cleared for Food Service: Yes Other diet restrictions: FISH ALLERGIES. — 07/30/2020 Comments: Allergies No Known Allergies Devices / Equipment C-Pap Travel: Direct Travel: No Travel Restrictions: None UNIVERSAL PRECAUTIONS OBSERVED WHEN TRANSPORTING ANY INMATE: Transfer From Institution: NEW YORK MCC Phone Number. 6468366300 Address 1: 150 PARK ROW Address 2: City/State/Zip: NEW YORK, New York 10007 Namerfltle of Person Completing Form: RN Dat Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 DOB: 01/20/1953 08/10/12019 Generated 08/10/2019 07:00 by RN Bureau olPrisons- NYM IVieroV94? ON EFTA_00000 1 5 3 EFTA00134688 Bureau of Prisons Health Services Vitals All Begin Date: 07/07/2019 End Date: 08/10/2019 Rog #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Temperature: Data Tiffin Fahrenheit Celsius Location EOM& 07/24/2019 13:12 NYM 97.8 36.6 Oral Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 NYM 97.5 36.4 Oral Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM 97.3 36.3 Oral Orig Entered: 07/09/2019 12:51 EST Pulse: Data _VMS Rate Per Minute I ()cation Rhythm Provider 07/30/2019 13:02 94 Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:40 88 Via Machine Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:30 87 Via Machine Orly Entered: 07/30/2019 12:59 EST 07/28/2019 20:28 81 Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 82 Orly Entered: 07/28/2019 06:58 EST RN 07/24/2019 13:12 83 Via Machine Regular Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 92 Via Machine Regular Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 82 Via Machine Regular Orig Entered: 07/09/2019 12:51 EST Respirations: Rate. Inn 07/30/2019 09:30 NYM Rate Per Minute. Provider 12 Orly Entered: 07/30/2019 12:59 EST 07/28/2019 20:28 NYM 14 RN Orlg Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 NYM 14 RN Orig Entered: 07/28/2019 06:58 EST RN 07/23/2019 06:30 NYM 16 Orly Entered: 07/23/2019 08:33 EST 91116 07/09/2019 12:49 NYM Orig Entered: 07/09/2019 12:51 EST Generated 0&1 0/2019 11:02 by Bureau of Prisons - NYM Pogo 1 of 3 ONY_00000945 EFTA_00000 1 54 EFTA00134689 Begin Date: 07/07/2019 End Dato: 08/10/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Blood Pressure: Pate. Time 07/30/2019 13:02 NYM Orig Entered: 07/30/2019 09:40 NYM Orig Entered: 07/30/2019 09:30 NYM Orig Entered: 07/28/2019 20:28 NYM Orig Entered: 07/28/2019 06:57 NYM Orig Entered: 07/24/2019 13:12 NYM Orig Entered: 07/23/2019 06:30 NYM Orig Entered: 07/09/2019 12:49 NYM Orig Entered: Blood Glucose: Date Time 08/04/2019 08:30 Orig Entered: 08/02/2019 06:30 Orig Entered: 08/01/2019 06:30 Orig Entered: 07/31/2019 06:15 Orig Entered: Value Location 114/84 Left Arm 07/30/2019 13:04 EST 125/60 Right Ann 07/30/2019 13:04 EST 108/86 Loft Arm Sitting 07/30/2019 12:59 EST 157/91 07/28/2019 20:29 EST 138/80 07/28/2019 06:58 EST 132/89 Right Arm 07/24/2019 13:14 EST 140/85 Right Arm 07/23/2019 08:33 EST 117/66 Right km 07/09/2019 12:51 EST Position Cuff Sin Provider Standing Standing Sitting Sitting Sitting Value fmg/dll Type 156 Non-Fasting 08/04/2019 09:08 EST 97 Non-Fasting 08/02/2019 08:16 EST 103 Non-Fasting 08/01/2019 09:00 EST 108 Non-Fasting 07/31/2019 08:36 EST Sa02: Date Time 07/30/2019 09:30 NYM Orig 07/28/2019 Orig 07/28/2019 Valuef%1 Alt 98 Room Air RN RN Adult-regular Adult-regular Adult-regular Milat Regular Insulin Provider Re Generated 08/10/2019 11:02 by Bureau of Prisons NYM Page 2 of 3 ONY_00000946 EFTA_00000155 EFTA00134690 Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date Emil Inches CIO Provider 07/09/2019 12:49 NYM 70.0 * 177.8 Orig Entered: 07109/201912:51 EST Weight: Datet Time Lits Kg Minn Provider 07/30/2019 09:30 NYM 194.2 88.1 Orig Entered: 07/30/2019 12:59 EST 07/09/2019 12:49 NYM 194.4 88.2 Orig Entered: 07/09/2019 12:51 EST Generated 08/10/2019 11:02 I Bureau of Prisons - NYM Page 3 al 3 S.0NY_00000947 EFFA_00000 1 56 EFTA00134691 Bureau of Prisons Health Services PPDs Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Adrnin: j,ocation 07/06/2019 21:39 Right Forearm Orig Entered: 07/06/2019 21:43 EST Total: 1 Provider Reading• induration 07/09/2019 12:47 0 mm Odg Entered: 07/09/2019 12:47 EST Generated 08/10/2019 11:02 RNAOPADC Bureau of Prisons - NYM SDNY_000C0Pet I °I l EFTA 00000157 EFTA00134692 76318454 EPSTEIN, JEFFREY Medication Orders Medication Administration Record JULY 2019 Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ob. Dim 07/1009 1421 Exp. Dee) 07/31/19 1001 NW 122148- NM/ PRN • e tr0ecl neck: Insulin reScuttrieousty per acting 544(J: niece Cary —pUJ Heir' for 7 days frepta, Reg (10 IA-) 100 UNITSR4L tri Ccd. Date 0701/19 1000 Ev. Data 08/07/19 0959 WM 122160- NYM Nect mauls Inaulth tigotaneously par sllepig scale: each In for 7 days ^pi0 Ono hau:n Reg (10 AC) 100 UNITS/ML etj PRN -PlovirletTYJ = JoaquIn:Y. Ocannonatian Codes: ORO = Order I NI = Dose Not Iodated Registration 0- 76318-054 Pt. Name: EPSTEIN. JEFFREY DOB: 01120/63 Report lnforma0on Is current as of lhe 0/1(0 end lane of printing: 08/100019 11:02 EST EFTA00134693 76318-054 04. Dan 07/31119 1899 Exp. On 0247119 0959 NYM 122160- ?NM EPSTEIN. JEFFREY Medication Orders Bornidote-i. Robert VD Ir*rt So' Ins win subcutanooesty per MOlag scale: oath rooming for 7 days "VII too"' IrouLot Rog (10 ML) 100 UNITSUL 04; Medication Administration Record AUGUST 2019 Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 PIN - Providers: YJ = JoarniarCiT Documentation Codes: ORO = Order I NI = Doso Not Indicated Registration 0: 76318-054 Pt. Name: EPSTEIN. JEFFREY DOB: 01/20/53 Report Infoana*n Is current as of the date and limo of printing 08/1072019 11:02 EST EFTA00134694 Bureau of Prisons Health Services Devices and Equipment Start Date: 07/07/2019 Stop Date: owl012019 Reg #: 76315-054 Inmato Name: EPSTEIN, JEFFREY EDWARD Peaks/Equipment Start Pate Stop Date Pate Returned Obtained From Comments C-Pap 07/30/2019 14:05 EST 07/3012019 Personal PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL. #: P1131281381 ED. Total: 1 Generated M1012019 11:02 by RNAOPP0C Bureau of Prisons - NYM Page t of SDNY_00000951 EFTA_00000160 EFTA00134695 Bureau of Prisons Health Services Pain Management Begin Date: 07/07/2019 Reg #: 76318-054 End Date: 08/10/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD =it Intervention, 07/12./2019 13:25 MEDROL DOSE PACK Orig Entered: 07/12/2019 13:28 EST Pain Quality Shooting Ls/crating Pig Post Provider Back-Middle 5 Generated 08/10/2019 11:02 by RN/1OPADC Bureau of Prisons - NYM soiftrag21 EFTA 00000161 EFTA00134696 Bureau of Prisons Health Services Modified Diet Re uest Types of Diets: Clear Liquid Exp Date: Low Fat Exp Date: Mechanical Soft Exp Date: Low Cholesterol Exp Date: Low Triglyceride Exp Date: Renal Exp Date: Full Liquid Exp Date: Sodium Controlled Exp Date: Snack Exp Date: Diabetic Exp Date: Calorie Controlled Exp Date: X Other. FISH ALLERGIES. Exp Date: 07/30/2020 Comments: EPSTEIN, JEFFREY EDWARD Inmate Name Health Service Staff 76318-054 07/30/2019 Reg# Date Generated 07/3012019 14:57 by Bureau of Prisons - NYM Page loll ONY_00000953 EFTA_00000 1 62 EFTA00134697 Bureau of Prisons Health Services Allergies Reg #: 78318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Allergy Pate Noted Reaction No Known Allergies 07/06/2019 OrIg Entered: 07/06/2019 21:40 EST Total: 1 Generated 08/10/2019 11:02 by Bureau of Prisons • NYM SON`;,aTotolL EFTA_00000 163 EFTA00134698 Bureau of Prisons Health Services Patient Education Assessments & Topics Reg IS: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Assessments Assessment Learns Rest By Primary I language Years of Education ers To Education 07/09/2019 Speaking/Listening English 12 None 0rig Entered: 071091201912:52 EST Total: 1 Pate Initiated Format Handout/Topic 07/30/2019 Counseling Access to Care Ong Entered: 07/30/2019 13:33 EST 07/30/2019 Counseling Plan of Care Orig Entered: 07/30/2019 13:34 EST 07/28/2019 Counseling Plan of Care Odg Entered: 07/28/2019 07:22 EST 07/28/2019 Counseling Plan of Care Orig Entered: 07/28/2019 20:30 EST 07/24/2019 Counseling Access to Care Orig Entered: 07/24/2019 13:23 EST 07/24/2019 Counseling Preventive Health Ong Entered: 07/24/2019 13:23 EST 07/23/2019 Counseling Access to Care Orig Entered: 07/23/2019 09:04 EST -07123/204-9— Counseling Plan oftare Orig Entered: 07/23/2019 09:04 EST 07/14/2019 Counseling . Diagnosis Orig Entered: 07/14/2019 18:11 EST 07/12/2019 Counseling Diagnosis Generated 08/1012019 11:02 by RMOPADC Topics Bureau of Prisons - NYM Outcome Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Provider Provider sot4c000cosPr EFrA_00000164 t of 2 EFTA00134699 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Topics Pate Initiated Format Hand Outcome Provider Orig Entered: 07/12/2019 13:33 ES Total: 10 L11 Gemmed oinomolidaliares. Terrance RNnOWIDC Bureau of Prisons • NYM Page 2012 EFTA00134700 Bureau of Prisons Health Services Blood Glucose Begin Date: 07/07/2019 End Dato: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD (Reference Range: Random or Fasting 70 - 100, 2 hour post-prandial 70 - 140) Data lama Yalua IY121 08/04/2019 08:30 NYM 156 Non-Fasting Orig Entered: 08/04/2019 09:08 EST RN 08/02/2019 08:30 NYM 97 Non-Fasting Orig Entered: 08/02/2019 08:16 EST 08/01/2019 06:30 NYM 103 Non-Fasting Orig Entered: 08/01/2019 09:00 EST 07/31/2019 06:15 NYM 108 Non-Fasting Orig Entered: 07/31/2019 08:36 EST Total: 4 Comments Page 104 1 SDNY_00000957 EFTA_00000166 Generated 08/1012019 11:02 by RN/IOPAIDC Bureau of Prisons - NYM EFTA00134701 Bureau of Prisons Health Services Health Problems Reg 01: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Descnotion Axle Code Type Code Ding Date Status. Current Hypertipidemla, unspecified 07/12/2019 13:48 EST ICD-10 E785 07/12/2019 Current HYPERTRIGLYCERIDEMIA Sleep apnea 07/12/2019 13:56 EST ICD-10 G4730 07/12/2019 Current Essential (primary) hypertension 07/30/2019 13:13 EST ICD-10 110 07/30/2019 Current BY HX. Constipation, unspecified 07/09/2019 12:58 EST ICD-10 K5900 07/09/2019 Current Low back pain 07/12/2019 13:30 EST ICD-10 M545 07/12/2019 Current Neuralgia and neuritis, unspecified 07/12/2019 13:30 EST ICD-10 M792 07/12/2019 Current No Diagnosis 07/09/2019 10:28 EST IL 0 .1 3 I DSM-IV No Dx 07/09/2019 Current is Prediabetes 07/30/2019 13:26 EST ICD-10 R7303 07/30/2019 Current Injury, unspecified 07/23/2019 09:04 EST ICD-10 T1490 07/23/2019 Current R/O self inflicted injuries. Body mass Index (BMI) 27.0-27.9, adult 07/30/2019 13:14 EST Total: 10 ICD-10 Z6827 07/30/2019 Current Generated 08/1O201911:02 by Ral/tOPADC Bureau of Prisons - NYM SDNY_00CO0PZ 1 EFTA 00000167 EFTA00134702 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/12/2019 13:10 Provider: Reg #: 76318-054 Facility: NYM Unit: 205 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDO/LIPID Subjective: 66 YR O1_ HYPERT 800 . MEDS HX OF O MACHINE. STATES THE L4 - L5 SEVERE LOWER EXTREMITIES. SURGICAL HX: NONE MENTAL HEALTH HX: Pain: Yes Pain Assessment Date: Location: Quality of Pain: Pain Scale: Intervention: Trauma Date/Year: Injury: Mechanism: Onset: Duration: Exacerbating Factors: Relieving Factors: Reason Not Done: Comments: HITE MALE WITH HX OF CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE EIR GI SIDE EFFECTS. UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. Y HAS SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE 07/12/2019 13:25 Back-Middle Shooting 5 MEDROL DOSE PACK 5+ Years 5+ Years NO EXERCISE MEDROL DOSE PACK Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology OBJECTIVE: Exam: General Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain. Pale. Pallor, Cyanotic, Diaphoretic. Disheveled, Unkempt, Acutely III Nutrition No: Appears Obese Generated 07/12/2019 Iik20 by Bureau of Prisons • NYM Page 1 of 3 SDNY_00000959 EFTA_00000 1 6 8 EFTA00134703 Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/12/2019 13:10 Provider: Reg #: 76318.054 Facility: NYM Unit: Z05 Exam: Eyes General Yes: Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal Si and S2 No: M/R/G Abdomen Auscultation Yes: Normo-Active B Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back Yes: Tenderness ithi Neurologic 41) Cranial Nerves (CN) Yes: W ASSESSMENT: Constipation, unspecified. K5900 - Current Motor Systemn Normal Limits -General Yes: Normal Exam Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current 4 0>e Sleep apnea, G4730 - Current PLAN: New Medication Orders: Bra Medication Order Date Prescriber Order Magnesium Hydroxide Susp 07/12/2019 13:10 30 CC Orally • Two Times a Day PRN x 2 day(s) Indication: Constipation, unspecified MethylPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 AS DIRECTED Orally - daily x Pack 21 tab) 6 day(s) Indication: Neuralgia and neuritis, unspecified Disposition: Generated 07/12/2019 14:20 by Bureau of Prisons • NYM SDNCISClig 3 EFTA_00000 1 69 EFTA00134704 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM l Encounter Date: 07/12/2019 13:10 Provider: Unit: Z05 Follow-up at Sick Call as Needed Other: WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP. Patient Education Topics: Date Initiated Formal 07/12/2019 Counseling Handout/Topic Diagnosis Copay Required:No F, Cosign Required: No TelephoneNerbal Order: Completed by , RQbetM i..n 07/12/2019 14:20 Provider Outcome , Robert Verbalizes Understanding Generated 07/12/2019 14:20 by Bureau of Prisons NYM Page 3 of 3 SDNY_00000961 EFTA_00000 1 70 EFTA00134705 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: 07/12/2019 13:10 Provider: Unit: Z05 Chronic Care -14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDO/LIPID Subjective: 66 YR OL HITE MALE WITH HX OF HYPERT CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , . STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS 9, EIR GI SIDE EFFECTS. HX OF O iS)14ii LIVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. '•1 q? HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE Y HAS L4 - L5 SEVERE SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMI S. SURGICAL HX: NONE MENTAL HEALTH HX: Pain: Yes Pain Assessment Date: 07/12/2019 13:25 Location: Back-Middle Quality of Pain: Shooting Pain Scale: 5 Intervention: MEDROL DOSE PACK Trauma Date/Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: Seen for clinic(s): Endocrine/Lipid. Pulmonary/Respiratory. Orthopedic/Rheumatology Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology OBJECTIVE: Exam: General Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic. Appears in Pain, Writhing in Pain, Pale. Pallor, Cyanotic. Diaphoretic. Disheveled, Unkempt. Acutely III Nutrition No: Appears Obese Generated 07/12/2019 14:20 by Bureau of Prisons • NYM Page 1 or 3 3DNY_00000962 EFTA_00000171 EFTA00134706 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01)20/1953 Sex: M Race: WHITE Encounter Date: 07/12/2019 13:10 Provider: Reg #: 76318-054 Facility: NYM Unit: Z05 Exam: Eyes General Yes: Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat d.Rhythm (RRR), Normal S1 and S2 No: M/R/G Abdomen Auscultation Yes: Normo-ActiveB 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: fix.# Ke_dkation Order Date Prescriber Order Magnesium Hydroxide Susp 07/12/2019 13:10 30 CC Orally - T o Times a Indication: Constipation, unspecified Day PRN x 2 day( MethyIRREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 AS DIRECTED Or ly - daily x Pack 21 tab) Indication: Neuralgia and neuritis, unspecified 6 day(s) Disposition: Generated 07/12/2019 14'20 by Bureau of Prisons • NYM Page 2 of 3 SONY_00000963 EFTA_00000 1 72 EFTA00134707 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg If: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: Unit: Z05 Follow-up at Sick Call as Needed Other: WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP. Patient Education Topics: Date Initiated Format 07/12/2019 Counseling Handout/Topic Diagnosis Copay Required: No Cosign Required: No TelephoneNerbal Order: Completed by n 07/12/2019 14:20 Pr_oytdes. Outcome Verbalizes Understanding Generated 07/12/2019 14:20 by Bureau of Prisons • NYM Page 3 of 3 SONY_000 00964 EFTA_00000173 EFTA00134708 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sox: M Race: WHITE Encounter Date: 07/14/2019 17:36 Facility NYM Amendment mado to this note by on 07/14/2019 18:11. Bureau of Prrsons - NYM SDNY_00000965 EFTA _00000174 EFTA00134709 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Note Date: 07/12/2019 09:08 Provider: Reg #: 76318-054 Facility: NYM Unit: Z05 Admin Note - Orders encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider. Robert MD PATIENT REQUESTED TO HAVE A COLACE RX , INSTEAD OF TEN BISACODYL FOR CONSTIPATION. New Medication Orders: Rx# Medication Order Date prescriber Order Dccusate Sodium Capsule 07/12/2019 09:06 TAKE ONE 1 rt MG CAP Orally - Two Times Day x 30 day(s) Indication: Constipation, unspecified Discontinued Medication Orders: adt Medication Order Date 121757-NYM Bisacodyl E.C. 5 MG TAB 07/1212019 09:06 Discontinue Type: When Pharmacy Processes Discontinue Roason:discontinue Indication: Copay Required: No TelephoneNerbal Order No Completed by Cosign Required: No on 07/12/2019 09:10 c ibe Take one tatAit (5 MG) by mouth at bedtime AS NEEDED for 10 days Generated 07/12/2019 09:10 by Wmw of Phone • NYM Page 1 al 1 SDNY_00000966 EFTA_00000 1 75 EFTA00134710 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Note Date: 07/07/2019 00:17 Provider. Reg #: 76318-054 Facility: NYM Unit: E06 Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider. MED CL:1 NO CCC APPT. Discontinued Laboratory Requests: Details Frequency Due Date Lab Tests-H-Hemoglobin A1C One Time 08/05/2019 00:00 R• no Lab Tests-C-CBC w/diff Lab Tests-L-Llpld Profile Lab Tests-C-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Rellex to Microscopic Additional Information: 66 y/o male, elevated BP Labs requested to be reviewed by: New Laboratory Requests: Details Frequency Due Date 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 Frequency End aak Due Pate Edo* General Radiology-Chest-2 Views One Time 07/25/2019 Ftouline 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 on 07/07/2019 00:30 Generated 07/072019 00:30 by Bureau of Prisons • NYM Pag• 1 of S NY 00000967 EFTA_00000 1 76 EFTA00134711 Bureau of Prisons Health Services History & Physical Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Dale: 07/09/2019 12:35 Provider M Race: WHITE 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+ Mate 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 Reg #: 78318461 Facility: NYM Unit 1 Gunennee 07/09/2019 13:03 by Bureau of Prisons - NYM gas EFFIC00000 177 EFTA00134712 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: Encounter Date: 07/09/2019 12:35 Provider. Unit 7; 18-054 HIV History: When Tested: 2019 Test Result: Negative Whon Diagnosod AIDS: Last CD4: Comments: Hepatitis: Denied Other Infectious Diseases: Syphilis: No Syphilis Last Treatment: N/A Genital Warts: No Chlamydia: Yes Gonorrhea: No Herpes: No Chicken Pox: Yes Other: No Comments: Chlamydia in 2015, treated Chicken pox in childhood Abuse History: Denied Physical: No Emotional: No Sexual: No Comments: Denies Gantt-aux' 07/022019 13:03 by Bureau of Prisons NYM iit8tott9 EFTA_00000 I 78 EFTA00134713 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/09/2019 12:35 Provider M Race: WHITE Reg W. 76318-054 Facility: NYM Unit 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 0710W2019 13:03 by ,ALP Bunanu of Prisons - NYM 386obbo EFTA 00000179 EFTA00134714 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/09/2019 12:35 Provider: Reg #: 76318-054 Facility: NYM Unit 1101 Observations: Draining Skin Lesions: No Signs of Lice: No Signs of Scabies: No Signs of Recent Trauma: No Recent Tattoos: No Needle Marks: No Signs of Rash: No Open Sores: No Wounds: No Body Deformities: No Tremors: No Sweating: No Comments: Generated 07,09/2019 13:03 by Bureau of Prisons - NYM 444 13 SONY_i 0000971 EFTA30000 1 80 EFTA00134715 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/09/2019 12:35 Provider: Joaquin, Y. MLP Reg #: 76318064 Facility: NYM Unit: H01 Immunizations: Hepatitis A and B (TwinRx) Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: 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 Dato: Provider: Location: Drug Mfg: Lot Number: Dosage: Routo: Exp Dt: Comments: Smallpox Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Tetanus Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Generated 07/09/2019 13:03 by Bureau of Prisons - NYM sgil006144,2 EFTA_00000 I 8 I EFTA00134716 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/09/2019 12:35 Provider. HITS Reg #: Facility: NYM Unit: 01 18-054 Immunization Date: Provider: Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Varicella Series Administration: History Unknown, Not Administered Documented Date: 07/09/201912:51 EST Immunization Date: Provider: Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Temperature: pa a Time Fahrenheit celsjua Location Emit 07/09/2019 12:49 NYM 97.3 36.3 Oral Pulse: Mgt I1m Rate Per Minute Location Pfivthrrt Provider 07/09/2019 12:49 82 Via Machine Regular Respirations: o Time Rate Per Minute Provider 07/09/2019 12:49 NYM 16 Blood Pressure: Thu Vat= Location Position Cuff Size Provider 07/09/2019 12:49 NYM 117/66 Right Arm Sitting Adult-regular SaO2: to Time YalueP/0) ALt provider 07/09/2019 12:49 NYM 97 Room Air Height: Da& Time Inches Cm Provider 07/09/2019 12:49 NYM 70.0 177.8 Generated 07/09/2019 13.03 by Bureau of Prisons - NYM 5 0973 EFTA_00000182 EFTA00134717 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: ITE Encounter Dale: 07/09/2019 12:35 Provider: Reg #: 76318-054 Facility: NYM Unit: H01 Date Time in_cheS _Ca Provider Weight: Date Time bits Kg Waist Circum astvider 07/09/2019 12:49 NYM 194.4 88.2 MNIM Prosthetic Devices/Equipment: Denied Tobacco Usage: Denied General Social History: Foreign Travel: Born in USA: Yes Country of Birth: USA Patient Education Assessments: Pate Ed Yrc Occupation Learns Best By PS a 07/09/2019 12 Balker Family History - Father. Age at Death: 74 Cause of Death: Diabetes complications Significant Illnesses: Diabetes Heart Disease Comments: Family History - Mother: Age at Death: 81 Cause of Death: Kidney Failure Significant Illnesses: Heart Disease Comments: Family History - Sibling: Numbor of Siblings: 1 Significant Illnesses: Comments: Past Hospitalization: Reason Acute Appendicitis Complications: None Comments: Head: Normal: Yes Comments: on Speaking/Listening English None Location Mount Sinai Hospital When 1990 Gorgated 07/C9/2019 13.03 by Bureau of Prisons - NYM ?of 13 SONY_ 0000974 EFTA_000001 83 EFTA00134718 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 8: ;318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/09/2019 12:35 Provider: Unit 1 Eyes: EOMI: Yes Icterus:No Conjunctival Inflammation: No Pupils Yes Pupil Size Rt: Pupil Size Lt: Pupils Comments: Fundi Vessels Nicking: No Fundi Vessels Discs Fiat:Yes Fund' Vessels Discs Sharp Margins:Yes Fundi Vessels Grounds Abnormal: No Eyes Comments: Vision Screen 07/09/2019 12:52 Blindness: With Corrective Distance Vision: OD: 100 OS: 70 OU: OD: OS Near Vision: OD: OS: OU: OD: OS: ishihara Color Test: Tonometry: L: R: Comments: Needs evaluation with optometrist. Ears: Right Ear: Canal patent Left Ear: Canal patent Ears Comments: Nose: Nares Patent: Yes Septum Midline:yes Septum Intact: Yes Drainage/Discharge: No Polyps: No Nose Comments: Generated 07/09/2019 13:03 by Bureau of Prisms - NYM SDNPIreOtggii EFTA_00000 1 84 EFTA00134719 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01120/1953 Sex: Encounter Date: 07/09/201912:35 Provider: M Race: WHITE Reg tr: 76318-054 Facility: NYM Unit: r 1 Mouth Lesions:No Oral/Buccal Mucosa:Yes Gums Normal: Yes Tonsils Present:Yes Tonsils Normal: Yes Pharynx: Normal Color Teeth Poor Dentition: No Teeth Count:Mostly Present Dentures: No Mouth Comments: Cranial Nerves: Intact II-Xll: Yes Cranial Nerves Comments: Neck: Full ROM:Yes Masses/Nodes: No Trachea: Midline Thyroid: Nomial Size Comments: Breasts: Normal: Yes Masses:No Tenderness:No Scars: No Dimpling:No Nipple Discharge: No Nipple Retraction:No Instructions for Self Breast Exam Given: Comments: No Generated 07/09/2019 13.03 by Bureau or Prisons - NYM 9d13 SDNY_ 0000976 EFTA_00000 1 85 EFTA00134720 Bureau of Prisons Health Services Vision Screens Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Vision Screen on Blindness: 07/09/2019 12:52 Distance Vision: OD: 20/100 OS: 20/70 OU: Near Vision: OD: OS: OU: With Corrective Distance Vision: OD: OS: OU: Near Vision: OD: OS: OU: Present Glasses - Distance Refraction - Distance Sphere Cylinder Axis Add Sphere Cylinder Axis R: R: L: L: Color Test Tonomotry: R: L: Comments: Needs evaluation with optometrist. Orig Entered: 07/09/2019 12:54 EST Generated 08110/2019 11:02 by Bureau of Prisons - NYM Pegs loft _00000977 EFTA_00000 1 86 EFTA00134721 Bureau of Prisons Health Services Immunizations Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Immunization Immunizathanato Administered Location Dosage Drug Mf cis Wit Txp Date Hepatitis A and B (TwinRx) History Unknown Orig Entered: 07/09/2019 12:51 EST Measles/Mumps/Rubella Series Orig Entered: 07/09/2019 1a51 EST Smallpox Series Orly Entered: 07/09/2019 12:51 EST Tetanus Orig Entered: 07/09/2019 12:51 EST Varicella Series Total: 5 Orig Entered: 07/09/2019 12:51 EST History Unknown History Unknown History Unknown History Unknown Generated 08/10/201911:02 by RN/IOP/IDC Bureau of Prisons -NYM sotic0000cgr 1 °I l EFTA_000001 87 EFTA00134722 Bureau of Prisons Health Services Medical Duty Status Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD - - . Houslog•Statife: tt" ,tr- . a. confined to the living quarters except _meals pill line _treatments Exp. Date: Exp. Date: Exp. Date: Exp. Date: Ptinta tli;g4DniiitsTSel1/2 :ttri: all spoil:4 Exp. Date: wsightftfting: _upper body lower body Exp. Date: ...ctsychavascular exercise: _running _jogging _walking softball Exp.. Date: on complete bed rest:.. .. bathroom privileges only X cell: eeN on first floor single cell X lower bunk airborne infection isolation other ' 'other: _football _basketball _handball stationary equipment • faletanagra urS areigiga niiiiig •';' Equipment Start Date C-Pap 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. W m tali Cleared for Food Service: Yes X No Restrictions Comments: N/A ttiatts:niart Health Services Staff • ;:dutu Exp. Date: End Date 10/09/2019 07/30/2019 elum Date Date Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 76318.054 Quarters: Z04 ALL EXPIRATION DATES' RE AT 24:00 • Generated 0811012019 1102 by Bureau or Prisons • NYM Anatol t NY_00000979 EFTA_00000 1 88 EFTA00134723 Bureau of Prisons Health Services Medical Duty Status Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD FiotastiV;SiliRSIL4 /4 : , — _ confined to the living quarters except meals pill line treatments Exp. Date: — on complete bed rest:,., -. bathroom privileges only Exp. Date: X cell: cell on first flijitor.. single cell X lower bunk airborne infection isolation Exp. Date: -.:1 4 other. Exp. Date: _ phigra • 0 Be-striefintc.:xfoga..4.4-m ..t.tvath:c.:- . .....srcer-• , +4:co•• tr4:::11-.3'0•61,e7.:2444.-:e.:1:. li:"...: ': • e., ...--....—. — all sports;1 • - 0.,, ;::' — west1Stm19: upper body lower body Exp. Date: Exp. Date: cardidyascular exercise: running _jogging walking softball Exp. Date: football basketball handball stationary equipment Exp. Date: 10/09/2019 ',avow°, mc irgabvioitumgrargoisilikattaism 2e-xmt,cs raj . Ir.74 graiWcWiiiffijaftemakifetetta ct5SszTh::": " ,1rt/Saa Cleared for Food Service: Yes X No Restrictions Comments: N/A Health Services Staff 07/09/2019 Date Inmate Name: EPSTEIN, JEFFREY EDWARD Reg ri: 76318-054 Quarters: Z04 ALL EXPIRATION DATES ARE AT 24:00 Generated 08110/2019 11:02 by Bureau of Prisons - NYM Parrott S 'NY 00000980 EFTA_00000189 EFTA00134724 Bureau of Prisons Health Services Medication Summary Historical Complex: NYM—NEW YORK MCC inmate: EPSTEIN, JEFFREY EDWARD Begin Date: 07/07/2019 End Date: 08/10/2019 Reg tt: 76318-054 Quarter: Z04-206LAD Medications listed reflect prescribed medications from the begin date to end date on this report. Allergies: Denied Active Prescriptions Bisacodyl E.C. 5 MG TAB Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10 days Rx#: 121757-NYM Doctor. Start: 07/09/19 Exp: 07/19/19 DIC: 07/12/19 Pharmacy Dispensings: 10 TAB 1 32 days Docusate Sodium 100 MG Cap Take one capsule (100 MG) by mouth twice dail for 30 days Rx#: 121823-NYM Doctor. Start 07/12/19 Exp: 08/11/19 Pharmacy Dispensings: 60 CAP in 29 days Docusate Sodium 100 MG Cap Take one capsule (100 MG) twice dail b mouth with lenty of water Rx#: 122084-NYM Doctor. Start: 07/26/19 Exp: 01/22/20 Pharmacy Dlspensings: 30 CAP In 15 days Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML shake well take 2 tablespoonful twice dal b mouth Rx#: 121835-NYM Doctor. Start: 07/12/19 Exp: 07/14/19 Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML shake well take 10ml by mouth twice daft AS NEEDED Rx#: 122150-NYM Doctor. Start 07/30/19 Exp: 10/28/19 methyiPREDNISolone 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 methylPREDNISolone 4 MG Tab ( 21 count Pack) Take the tablet by mouth as directed Rx#: 122149-NYM Doctor: Start: 07/30/19 Exp: 08/05/19 Generated 08110/2019 11:02 by Pharmacy Dispensings: 473 ML In 29 days Pharmacy Dispensings: 473 ML in 11 days Pharmacy Dispensings: 21 tab in 29 days Pharmacy Dlspensings: 21 tab In 11 days Bureau of Prisons - NYM Page 1 of 2 SONY 00e00981 _ EFTA_00000190 EFTA00134725 Complex: NYM—NEW YORK MCC Inmate: EPSTEIN. JEFFREY EDWARD Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Quarter. Z04-206LAD Active Prescriptions Omega 3 (Vascepa) 1 GM Capsule Take two capsules (2 GM) twice daily b mouth with food Rx#: 121885-NYM Doctor: Start: 07/17/19 Exp: 01/13/20 Pharmacy DispensIngs: 180 Cap in 24 days Insulin Reg (10 ML) 100 UNITS/ML Inj Inject regular insulin subcutaneous/ er slidin scale: twice daily line— for 7 days "'pill Rx#: 122148-NYM Doctor: Start: 07/30/19 Exp: 08/06/19 D/C: 07/31/19 Pharmacy DispensIngs: 0 ML in 11 days Insulin Reg (10 ML) 100 UNITS/ML Inj Inject regular insulin subcutaneous) er sliding scale: each morning for 7 days —pill lino— ***pill Blfe Rx#: 122160-NYM Doctor: Start: 07/31/19 Exp: 08/07/19 Pharmacy DIspensIngs: 0 ML in 1 days Generated 08/102019 11:02 by Bureau of Prisons - NYM Page 2 of 2 SONY_00000982 EFTA_00000 191 EFTA00134726 Bureau of Prisons Health Services Dental Health History Screen Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/26/2019 07:54 Provider. Unit H01 54 ASSESSMENTS: Health Problems as of Dental Health History Encounter date: 07/26/2019 07:54 Health Problems Health Problem 5181O. Hypertipiderrda, unspecified Current HYPERTRIGLYCERIDEMIA Steep apnea Current Constipation, unspecified Current Low back pain Current Neuralgia and neuritis, unspecified Current No Diagnosis Current Injury, unspecified Current R/0 self inflicted injuries. Medical History as of Dental Health History Encounter date: Medical History: Allergies: Denied Seizures: Denied Diabetes: Denied Cardiovascular: Denied CVA: Denied Hypertension: Denied Respiratory: Denied Sickle Cell Anemia: Denied Carcinoma/Lymphoma: Denied HIV History: When Tested: 2019 Test Result Negative When Diagnosed AIDS: Last CD4: Comments: Hepatitis: Denied 07/26/2019 07:54 Gorarated 07/28/2019 07:59 by Maum, Cheryl 008 Bureau el Prisons • NYM Page 1 of 3 NY_00000983 EFTA_0000019/ EFTA00134727 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 7631 Date of Birth: 01/20/1953 Sex: M Facility: NYM Encounter Date: 07/26/2019 07:54 Provider. Unit: H01 Other Infectious Diseases: Syphilis: No Syphilis Last Treatment: N/A Genital Warts: No Chlamydia: Yes Gonorrhea: No Herpes: No Chicken Pox: Yes Other: No Comments: Chlamydla in 2015, treated Chicken pox in childhood Other Health Issues: Other Medical Conditions And Treatment:sleep apnea Current Medical Conditions: Other Current Treatments: Pregnant: N/A Dental Observations as of Dental Health History Encounter date: 07/26/2019 07:54 History: Alcohol: No Mothamphetamine: No Tobacco products: No Other drugs: No Sensitive tooth: No Bleeding gums: Yes Food impaction: Yes Pain around ear: No Toothache: No Wear partial dentures: No Unusual sounds while eating: No Snoring: Yes Blisters on lips or mouth: No Clenching or grinding: Yes Swelling or lumps In mouth/throat: No Burning tongue: No Bad breath: No Decayed teeth: No Loose teeth: No Wear dentures: No None: No Comments: Generated 07128/2019 07:59 by Eturuau of Prisons - NYM NOIM2 Or 3 S Y_00CO0984 EFTA_00000193 EFTA00134728 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/26/2019 07:54 Provider. Unit: H01 Cardiac Condition Requiring Prophylaxis: No Prosthetic JoInt(s): No Radiation history of head or neck: No Excessive bleeding: No Bisphosphonates: No Comments: Medications as of Dental Health History Encounter date: 07/26/2019 07:54 Medications: Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take one capsule (100 MG) by mouth twice da4 for 30 days Omega 3 (Vascopa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by mouth with food OTCs: Listing of all known OTCs this inmate is currently taking. Instructed inmate how to obtain medical, dental, and mental health care. Copay Required:No TelephoneNerbal Order No Completed by Cosign Required: No on 07/26/2019 07:59 Generated 07126/2019 07:59 by Bureau of Prison,. NYM gaol 3 ON _00000985 EFTA_00000 1 94 EFTA00134729 Bureau of Prisons Health Services Dental A&O Exam Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #:. 76318-054 Date of Birth: 01/20/1953 Facility: NYM Encounter Date: 07/26/2019 07:47 Sex: F rovi M der: ISSN Unit H01 Reviewed Health Status: Yes Occlusion: Class I Oral Hygiene: Fair CPITN: 3 2 1 3 3 2 3 Hard and soft tissue examination performed and documented on BP618 form: Yes Head & Neck/Soft Tissue within normal limits? No Comments: moderate to advanced upper posterior gingival recession Decayed: Missing: Filled: 0 1 14 Comments: Lower anterior crowding Approved for hygiene appointment and radiographs: Yes Instructed Inmate how to obtain routine and emergency dental care. Oral hygiene instructions Ivan: Yes Dental A&O Screening Exam findings entered on EPSTEIN, JEFFREY EDWARD by 07/26/2019 07:47, on Generated 07/2612019 08:00 by Bureau of Prisons NYM Page 1 of 1 S NY_00000986 EFIA_00000195 EFTA00134730 Bureau of Prisons Health Services Dental Soap/Admin Encounter Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: Date of Birth: 01/20/1953 Sex: Dental Facility: Encounter Date: 07/18/2019 13:48 Provider: Dental Asst Unit: 76318-054 NYM ZO5 Screening encounter at Dental Clinic. Reason Not Done: Unavailable Comments: Patient has had several call outs for his Dental A & 0 screening but has not been escorted to the dental clinic. Cosign Required: No Completed by Dental Asst on 07/19/2019 13:49. Generated 07/19/201913:09 by DeBruca JUarlha Dental Bureau of Prisons • NYM Page 1 of 1 S NY_00000987 EFTA_00000196 EFTA00134731 Federal Bureau of Prisons U.S. Medical Center for Federal Prisons 1900 W. Sunshine Street Springfield, MO 65807 417-874-1621 "' Sensitive But Unclassified "' Name EPSTEIN. JEFFREY Reg U 76318-054 DOB 01/20/1953 Sex M Facility MCC New York Order Uni Provider SS= 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) GFR units measured as mL/min/1.73 m"2. If African American multiply by 1.210. A calculated GFR <80 suggests chronic kidney disease if found over a 3 month period. Calcium 9.8 Glucose 102 AST H 57 ALT 62 Alkaline Phosphatase 64 Blirubin, Total 1.1 Total Protein 7.3 Albumin 4.4 Globulin 2.9 Alb/Glob Ratio 1.50 Anton Gap 10.2 BUN/Creat Ratio 16.1 Cholesterol H 216 Triglycerides Calculation cf LDL is not appropriate for samples with a triglyceride greater than 400 mg/dL. Therefore the LDL is not calculated. HDL Cholesterol L 31 40-60 mg/dL Chol/HDL Ratio H 6.9 0.0-4.0 137 4.7 99 27 17 1.05 >60 413 137-148 3.5-5.0 99-114 22-30 7-22 0.66-1.25 8.5-10.9 70-110 11-55 11-66 41-133 0.2-1.3 6.0-8.2 3.6-5.1 2.0-3.7 1.00-2.30 9.0-19.0 5.0-30.0 <200 10-150 mmoUL mmoUL mmoUL mmoUL mg/dL mg/dL mg/dL mg/dL U/L U/L U/L mg/dL g/dL g/dL g/dL mg/dL mg/dL HEMATOLOGY WBC NRBC% RBC Hemoglobin Hematocrit MCV MCH MCHC RDW-CV Platelet L 7.6 0.0 5.42 15.6 47.8 88.2 28.8 32.6 12.8 338 4.3-11.1 4.46-5.78 13.6-17.6 40.2-51.4 82.5-96.5 27.1-34.9 33.0-37.0 12.0-14.0 130-374 KfuL MAIL ti P9 g/dL K/uL FLAG LEGEND L=Low Lt=Low Critical H=I-figh H!=High Cntical A=Abnorrnal Al =Abno al Critical Page 1 of MC00000988 EFTA_00000197 EFTA00134732 Federal Bureau of Prisons U.S. Medical Center for Federal Prisons 1900 W. Sunshine Street Springfield, MO 65807 417-874-1621 ••• Sensitive But LInciassifted Name EPSTEIN, JEFFREY Reg # 76318-054 DOB 01/20/1953 Sex M Facility MCC New York Order Unit E06-547U Provider IME MM. MD HEMATOLOGY MPV Neutrophils % Therapeutic dedsion making should be based on absolute values, rather than percentages Lymphocytes % Monocytes % Eosinophils % Basophils % Immature Granulocytes % NeutrophIls # Lymphocytes # Monocytes # Eosinophits # Basophils # Immature Granulocytes 10.4 58.7 25.0 11.1 4.1 0.8 0.3 4.4 1.9 0.8 0.3 0.1 0.02 HEMOGLOBIN A1C Hemoglobin A1C 5.7 -6.4 Increased Risk > 6.4 Diabetes 6.3 Collected 07/09/2019 13:34 Received 07/1012019 10:44 Reported 07/10/2019 14:46 LIS ID 188191004 6.9-10.6 IL cto 0.0-5.0 1.9-6.7 K/uL 1.3-3.7 K/uL 0.3-1.1 K/uL 0.0-0.5 K/uL 0.0-0.1 K/u L 0.00-0.50 10"3/uL <5.7 SEROLOGY RPR Non-Reactive Results may be affected in patients with severely advanced immunosuppression. Non-Reactive FLAG LEGEND L=Low LI=Low Critical H=High H!=High Critical A=Abnorrnal Al =Abno-mal Critical Page 2 of 3 SDNY_00000489 EFTA 00000 1 98 EFTA00134733 @ Federal Bureau of Prisons U.S. Medical Center for Federal Prisons 1900 W. Sunshine Street Springfield, MO 65807 417-874-1621 Sensitive But Unclassified ••• Name EPSTEIN, JEFFREY Reg # 76318-054 DOB 01/20/1953 Sex M Facility MCC New York Order Unit E06-547U Provider MD Collected 07/09/2019 13:34 Received 07/10/2019 10:44 Reported 07/10/2019 14:46 LIS ID 188191004 HIV HIV 1/2 Negative Screening test - Soo confirmatory losing for Reactive results Negative FLAG LEGEND L=Low LI=Low Critical I-I=High IiI=High Critical A=Abnormal Al =Abnormal Critical Page 3 of 3I soNk_00000sso EFTA_00000199 EFTA00134734 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 on 07/14/2019 18:12. Bureau of Prisons - NYM SONY_00000991 EFTA_00000200 EFTA00134735 BP-S358.060 MEDICAL TREATMENT REFUSAL COMM SEP C6 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24.2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental CO 'Won, and release the Buroau of Prisons and Its employees from any and all liability for respecting and f• owing my expressed wishes and directions. 7-24-2019 Counseled by Dale a is Sign NYM—NEW YORK MCC Date SDN _00000992 EFIA_0000020 EFTA00134736 BP-A0618 A&O DENTAL EXAMINATION JUN 18 (Initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Occlusion: 1 2 3 4 5 8 7 8 9 1011 1213 14 15 18 32 31 30 28 28 27 2825 24 23 22 21 20 19 16 17 re Ir Oral Hygiene: Good Fair / oor CPITN: 3 3 2- 9 Head & Nock / Soft natio: 1C7 t 1 F: Clessilficatiom CLT Pain Scale: /10 Dental Prostheses at Intake: Yes 0 Type: Age: Cannon: rColmreoll rtu ssicy, la -)e--r r'" " i j We:JM In i ' v i m Di:. Seru-e- --.4c1 or (TOW: i itiCi , I►0 SCP-14 lntra-cral Photos Taken: Yes 0 Radiographs Taken: (Document findings on MO &Mounter) Yes 9 Instructed how to obbarn urgent and non-urgent dental care Yes: 1 Noc Treatment PrImites: None: Ncn-urgent non-urgent Urgent Referred to Sick Call: Ftactlographs authorized PM: Prczahylaxiq authorized: Yes I No (Approval vat 18 months from examinant, date) SW5: Patton= Pa t Name: , skin , -376--chy s 0 • • el 9. RDS 7(:, Nunber: I 3 I Sr- OS-L3/4 institution: / MCC NEW YORK Date: 7- 2 O Signature Block/Stamp: -DDS. PDF l:hlel Uental r MCC New York • Presorted by P84O) RcVaces BRAopte olJUN 10 SDNY_II0000993 I EFTA_00000202 EFTA00134737 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318 Date of Birth: 01/20/1953 Sex: gaggg;,..VUITE Facility: NYM Encounter Date: 07/28/2019 20:25 Provider: Ell=1=1. RN Unit: H01 Nursing - Follow up encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: RN Chief Complaint Neuropathy - Tingling/Numbness of Extremity(ies) Subjective: Inmate seen for F/U after returning from attorney conference offers no new complaints or worsening S/S Mats ° My R hand still has pins and needles sometimes' No change in appearance from previous exam. Pain: No OBJECTIVE: Pulse: Data lime Rate Per Minuto Location Rhythm Provider 07/28/2019 20:28 81 RN Respirations: Date Brae Rate Per Provider 07/28/2019 20:28 NYM 14 RN Blood Pressure: Date Lime Value Location Position Cuff Sin provider 07/28/2019 20:28 NYM 157/91 SaO2: Date. Time Vaitte(%), Air Provider 07/28/2019 20:28 NYM 98 RN Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 Nutrition Yes: Within Normal Limits Skin General Yes: Within Normal Limits, Dry, Skin Intact ASSESSMENT: No Significant Findings/No Apparent Distress PLAN: Disposition: To be Evaluated by Provider Generated 07/28/201920:30 by RN Bureau of Prisons- NYM Page 1 of 2 NY_00000994 EFTA_00000203 EFTA00134738 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg it 76318-054 Date of Birth: 01/20/1953 Sex: TE Facility: NYM Encounter Date: 07/28/2019 20:25 Provider. RN Unit 1-401 Forow-up in 12-24 Hours Patient Education Topics: Pate Initiated f ormiti Panclout/Topic 07/28/2019 Counseling Plan of Care Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Compieted by RN on 07/28/2019 20:30 Requested to be cosigned by Cosign documentation will be displayed on the following page. Sim Outcome Verbalizes Understanding Generated 07/2812019 20:30 by RN Burciou of Prisms - WI/ Pan 2 d 2 DNY_00000995 EFTA_OOOOO204 EFTA00134739 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Race: WHITE Encounter Date: 07/28/2019 20:25 Provider: SEM RN Facility: NYM Cosigned by on 07/28/2019 20:50. Bureau of Prisons - NYM SDNY_00000996 EFTA_00000205 EFTA00134740 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: larial iTE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider. RN Unit: H01 Nursing - Triage Note encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: RN Chief Complaint: Neuropathy - Tingting/Numbness of Extremity(ies) Subjective: ' I woke up and I had no control over my Right arm for a few minutes it was just doing what it wanted to dos Pain: No OBJECTIVE: Pulse: Plata Time RAW Per Minute I-ocation Rhythm Provider 07/28/2019 06:57 82 Respirations: Pate ILnti Rate Per Minute Provider 07/28/2019 06:57 NYM 14 RN Blood Pressure: Rate Lola Value lacatton Pasitign Cuff Size Provider 07/28/2019 06:57 NYM 138/80 SaO2: Data Time Valuef%). Alt 07/28/2019 06:57 NYM 98 Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 Skin General Yes: Within Normal Limits, Dry, Skin Intact Provider Head General Yes: Symmetry of Motor Function, Atraumatic/Norrnocephalic No: Facial Asymmetry, Battle's Sign, Raccoon Eyes, Deformity Eyes General Yes: Extraocular Movements Intact RN Face General Yes: Symmetric Generated 07/28/2019 07:22 by RN Bureau or Prisons-NYM Pa pe 1 al 3 NY_00000997 EFFA_00000206 EFTA00134741 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: et ssWHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: RN Unit 1101 Exam: No: Ecchymosls, Numbness, Swelling, Perlorbital Edema Neck General Yes: Abrasion(s) Pulmonary Observation/Inspection Yes: Within Normal Limits No: Respiratory Distress, Tachypnea, Hyperventilation Cardiovascular Observation Yes: Normal Rate Musculoskeletal Shoulder Yes: Full Range of Motion R, Symmetric R No: Swelling R, Inflammation R Humerus Yes: Within Normal Limits R Elbow Yes: Normal Exam R, Full Range of Motion R, Non-Tender on Palpation R Radius / Ulna Yes: Normal Exam R, Full Range of Motion R Wrist/Hand/Fingers Yes: Full Range of Motion R, Non-Tender on Palpation R, Swelling R No: Inflammation R, Ecchymosis R, Erythema R, Tenderness R, Laceration(s) R, Abrasion(s) Contusion(s) R ROS Comments Received inmate AAOX3 In no acute distress, speaking in full sentenced ambulating independently C/ Right 8/771 numbness after waking up from 'sleeping on my side' that has since subsided. Inmate interviewed in psyc obs through the slot V/S noted WNL, RR even and unlabored, no neurological deficits noted, no facial droop slurred speech or dysphagia, Inmate with Full ROM to all extremities with 4/4 strength bilaterally, slight swelling noted to right phalanges when compared to left, no edema, erythema or ecchyrnosis noted. Denies aiirliumbness or tingling at this time. Denies any Chest pain, Headache, Dizziness, SOB or Blurred vision. Eyes MD on Call notified, Re-evaluate this evening or sooner if S/S persist. ASSESSMENT: Alteration in comfort PLAN: Disposition: Follow-up at Sick Call as Needed Notify Medical Duty Officer Patient Education Topics: Pate Initiated Format Handout/Tonic provider Outcome 07/28/2019 Counseling Plan of Care Columbo, Joseph Verbalizes Understanding Generated 07/28f2019 07:22 by-RN Bureau of Prisons • NYM Page 2 of 3 SONY 00000998 EFTA_00000207 EFTA00134742 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Bit 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: SRN Unit: H01 Date Initiated Esimat Handout/Tonic Copay Required: No Cosign Required: Yes TelephoneNerbal Order: No Completed by RN on 07/28/2019 07:22 Requested to be cosigned by Cosign documentation will be displayed on the following page. Provider outcome Generated 07128/2019 07:22 by RN Bureau or Prisons - NYM Pep 3 of 3 Y_00000999 EFTA 00000208 EFTA00134743 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg N: 76:18-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/28/2019 06:51 Provider: RN Facility: NYM Cosigned by on 07/2812019 20:51. Bureau of Prisons- NYM S NY 00001000 EFTA_00000209 EFTA00134744 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: Date of Birth: Note Date: EPSTEIN, JEFFREY EDWARD 01/20/1953 Sex: TE 07/26/2019 08:57 Provider-. Reg #: Facility: Unit: 76318-054 NYM HO Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider. THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. New Medication Orders: Sxli Medication Docusato Sodium Capsule Indication: Copay RoquIrod:No TelephoneNerbal Orden No Completed by Garroted 07/262019 OB:58 by Constipation, unspecified Cosign Required: No on 07/26/2019 08:58 Order Date 07/26/2019 08:57 atteau ol Prisons - NYM Prescriber Order TAKE ONE 10 MG CAP Orally - Two Times a Day x 180 day(s) Page') of 1 S NY_00001001 EFFA_00000210 EFTA00134745 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Reg ft: 76318-054 Date of Birth: 01/20/1953 Provider: Sex: Facility: NYM Note Date: 07/24/2019 16:10 H01 Unit: Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. Copay Required:No Cosign Required: No TelephoneNerbal Order: No Completed by-. Robe 4/2019 16:12 Generated 07/24/201916:12 by Bureau of Prisons - NYM Page lot I SDNY_00001002 EFTA_00000 2 1 1 EFTA00134746 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Reg tr: 76318-054 Date of Birth: Note Date: 01/20/1953 07/24/2019 16:10 Sex: SWIMSFacility: Provider: Unit: NYM 1-101 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. Copay Required:No TelephoneNerbal Order: No Completed by allal Robe Generated 07/24/2019 16.12 by Cosign Required: No 24/2019 16:12 Bureau of Prisons - NYM Page 1 of 1 SONY 00001003 EFTA_00000 2 12 EFTA00134747 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/26/2019 08:57 Facility: NYM Amendment made to this note b on 07/26/2019 08:58. Bureau of Mora - NYM SDNY_00001004 EFTA_000002 3 EFTA00134748 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: la m ilair m Facility: NYM Note Date: 07/24/2019 15:10 Provider: Unit: I-101 Admin Note - General Administrative Note encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: PATIENT WAS OFFERED TO HAVE AN OPTOMETRIST EVALUATION. HE REFUSED. REFfISAL FORM SIGNED. Copay Required:No TelephoneNerbal Order No Completed by Cosign Required: No on 07/24/2019 15:17 Generated 07/24/2019 15:17 by Bureau of Prisons • NYM Page 1 or 1 NY 00001005 EFTA_000002 14 EFTA00134749 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: TE Facility: NYM Encounter Date: 07/24/2019 13:08 Provider. Unit: H01 Mid Level Provider - Follow up Visit encounter performed at Receiving & Discharge. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: I still do not want to talk about. But, between you and me. I think my room mate had to do with what happened to me. Do not ask me. I am not going to say anything. Pain: No OBJECTIVE: Temperature: Data Time Fahrenheit Celsius Location 07/24/2019 13:12 NYM 97.8 36.6 Oral Provider Pulse: Data Time Rate Per Minute Location Rhythm PtoxIdar 07/24/2019 13:12 83 Via Machine Regular Blood Pressure: Rata Time Valua Location Position Cuff Size 07/24/2019 13:12 NYM 132/89 Right Arm Sitting Adult-regular Sa02: Data Time Valuer/01 Alr Provider 07/24/2019 13:12 NYM 96 Room Air Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Appears in Pain Fxam Comments Follow up evaluation done for inmate Epstein. He does not look In any pain or distress. He still has the erythema around his neck. Central part of this erythema has some abrasion. Patient do of any respiratory problem or distress. He all does not want to explain how the skin Injury on his neck Insinuates that injuries on his neck have to do with his room mate. But does not want to talk about it. ASSESSMENT: Injury, unspedfied, T1490 - Current PLAN: Disposition: Genureled 07/20/2019 13:24 by Bureau of Prisms - NYM s not complaint apped. he Page 1 of 2 SDNY_00301006 EFTA_000002 15 EFTA00134750 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: rrE Facility: NYM Encounter Date: 07124/2019 13:08 Provider: Unit: 1101 Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format Handout/Topio 07/24/2019 Counseling Access to Care 07/24/2019 Counseling Preventive Health Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Completed by on 07/24/2019 13:24 Requested to be cosigned by Cosign documentation will be displayed on the following page. Outcomq Verbalizes Understanding Verbalizes Understanding Gcnorulod 07/24/2019 13:24 by Eluroau of Prisons • NYM Page 2 of 2 NY 00001007 EFTA_000002 16 EFTA00134751 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/24/2019 13:08 Provider ims Reg #: 76318-054 Race: WHITE Facility NYM Cosigned with New Encounter Note by IIIIIIMMEMon 07/24/2019 16:10. Sumo at Prisons • NYM SONY 00001008 EFTA_00000217 EFTA00134752 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: ITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider. Unit: H01 Injury Assessment • Non-work related encounter performed at Health Services. SUBJECTIVE: INJURY 1 Provider: Date of Injury: 07/23/2019 01:27 Work Related: No Work Assignment: UNASSG Pain Location: Pain Scale: Pain Qualities: Where Did Injury Happen (Bo specific as to location): Special Housing Unit 205-Cell 124 L Cause of Injury (Inmate's Statement of how injury occurred): 'I do not know. Just went to drink a little water and wake up snorting'. Symptoms (as reported by Inmate): None Date Reported for Treatment: 07/23/2019 08:25 OBJECTIVE: Temperature: Rain Mitt Fahrenheit Celsius 1-ocatiort Provider 07/23/2019 06:30 NYM 973 36.4 Oral Pulse: DnW Time Rate Per Minute .1.ocation. Rhythm Provider 07/23/2019 06:30 92 Via Machine Regular Respirations: Pitt Time Rate Per Minute Provider 07/23/2019 06:30 NYM 16 Blood Pressure: Data Time Value bocation Position Cuff Size ErOvid_er 07/23/2019 06:30 NYM 140/85 Right Ann Sitting Adult-regular SaO2: Bata Time Valuer/01 Air 07/23/2019 06:30 NYM 96 Room Air 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, Ger,erb:od 0723/2019 01.05 by Bureau of Prisms • NYM Page 1 of 2 SONY 00001009 EFTA_0000021 8 EFTA00134753 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: ITE Encounter Date: 07/23/2019 06:20 Provider. Reg #: 76318-054 Facility: NYM Unit: H01 Exam: Acutely III Pulmonary Auscultation Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally No: Crackles, Fthonchi, Wheezing Fxam Comments Inmate for injury report as requested by Operational Lt. He is ambulatory, oriented x 3. In not apparent distress, smiling during this clinical encounter. Alleges, that he does not know what happened. Can not explain the marks on his neck. Responded: I don't know°. He does not want to talk of the events leading to the marks on his neck. He does not look in any distress or pain. Has an circular line of erythema at the base of the neck. Reaching 2/3 of the neck circumference, 2 inch wide, sparing the back of the neck. Has one section of this erythema in the front with marks of friction. No inflammation, no deformities, no hematomas, no lacerations, no tenderness. Patient moving his neck without any restriction. Denies having any pain or discomfort. Denies any respiratory problem. Has another small erythema on left knee about 2cm In dlameler(mild). As per Information from custody staff inmate Epstein was found in his cell with a rope around his neck a sitting on the floor. Inmate is currently placed on suicide watch. ASSESSMENT: Injury, unspecified, T1490 - Current - R/O self Mflicted injuries. PLAN: Disposition: Fe:low-up at Sick Call as Needed Placed on Suicide Watch Fellow-up in 2-4 Hours Other: For follow up with psychology service. Patient Education Topics: natiunitiatad Emma Handout/Topic flia• Outcome 07/23/2019 Counseling Access to Care Verbalizes Understanding 07/23/2019 Counseling Plan of Care Verbalizes Understanding Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Completed by on 07/23/2019 09:05 Requested to be cosigned by Cosign documentation will be displayed on the following page. Generated 07/23/2019 09:05 by Bureau of Prisons NYM Page 2 of 2 SONY 00001010 i EFTA_000002 19 EFTA00134754 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg tt: 76318-054 Date of Birth: 01/20/1953 Sex: Race: WHITE Encounter ()ate: 07/23/2019 06:20 Provider. REM Facility: NYM Cosigned by n 07/23/2019 15:44. 81.1/011t1 of Prisons • WM NY 00001011 EFT/C00000110 EFTA00134755 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07114/2019 17:36 Sex: Provider: Reg 1$: 76318 M Race: WHITE Facility: NYM Unit: Z05 54 Chronic Care -14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDO/LIPID Subjective: 66 YR OLD WHITE MALE WITH HX OF HYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRI L WAS 800 , NOW 431. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERID MEDS DUE TO THEIR GI SIDE EFFECTS. HX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CP MACHINE. STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTE STATES THE FBI LOKELY HAS L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES. SURGICAL HX: NONE MENTAL HEALTH HX: NONE Pain: Yes Pain Assessment Dato: 07/12/2019 13:25 Location: Back-Middle Quality of Pain: Shooting Pain Scale: 5 Intervention: MEDROL DOSE PACK Trauma Date/Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: Reason Not Done: Comments: MEDROL DOSE PACK Soon for clinic(s): OrthopedidRheumatology, Pulmonary/Respiratory, Endocrine/Lipid Added to clinIc(s): OrthopedldRheumatology, Pulmonary/Respiratory, Endocrine/Lipid OBJECTIVE: Exam: General Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears In Pain, Writhing in Pain, Pale. Pallor, Cyanotic, Diaphoretic. Disheveled, Unkempt, Acutely III Nutrition No: Appears Obese Generated 07/14/2019 18:11 by Bureau of Prisons • NYM Page I of 3 S NY_00001012 EFTA_00000221 EFTA00134756 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sox: M Race: WHITE Facility: NYM Encounter Date: 07/14/2019 17:36 Provider: Unit: Z05 Exam: Eyes General Yes: Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2 No: MIRJG Abdomen Auscultation Yes: Norma-Active Bowel Sounds Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back Yes: Tenderness Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam ASSESSMENT: Constipation, unspecified, K5900 - Current Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: Siff Medication Order Date Omega 3 ( Vascepa) 1 GM Capsule 07/14/2019 17:36 Indication: Hyperlipidemia, unspecified New Laboratory Requests: Retails Frequen Lab Tests-H-Hemoglobin A1C One Time Lab Tests-L-Lipid Profile Additional Information: Gonoralad 07/14/201918:11 by Buroau of Prisons NYM Rue Pate 10/10/2019 00:00 Routine Prescriber Order TAKE 2 CAPS (cagy - Two Times a Day x 1 dey(s)— TAKE WITH FO . Pea 2 of 3 SDNY_00001013 EFTA_00000222 EFTA00134757 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/14/2019 17:36 Provider: Reg #: 76318-44 Facility: NYM Unit: Z05 FASTING. Lab Tests-H-I-tep B surface Ab 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: One Time 08/08/2019 00:00 Routine PENDING EKG AND FOBT. CXR WAS REFUSED. Patient Education Topics: Datsigitialeti Format flandouttropig 07/14/2019 Counseling Diagnosis Copay Required:No TeiephoneNerbal Order: No Completed by Cosign Required: No on 07/14/2019 18:11 Robe glitcnffit Verbalizes Understanding Genuretsd 07114/2019 19:11 by Bureau of Prisons NYM Page 3•21 3 SON _want:an EFTA_0000022 3 EFTA00134758 BP-S358.060 MEDICAL TREATMENT REFUSAL SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS CDFRM 7-24-2019 Date I JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Fe eral Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment l 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. 7-24-2019 Counseled by Date is Sign NYM-NEW YORK MCC S NY_00001015 • EFTA_00000224 EFTA00134759 BP-S358.C60 MEDICAL TREATMENT REFUSAL CDFRbf SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-10-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: 66 YR OLD MALE WITH NO PMI-IX , REFERRED FOR ROUITNE CXR. The following treatment(s) was/were recommended: CHEST X-RAY • Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: WORSENING THE CONDITION IF THERE IS ANY FINDINGS • • I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. 7-10-2019 Counseled by Date Signature of Witness Patien Date NYM-NEW YORK MCC NY_00001016 EFFA_00000225 EFTA00134760 BP-5358.060 SEP OS U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS MEDICAL TREATMENT REFUSAL CDFI1M 7-24-2016 Date I, JEFFREY EPSTEIN 76318.054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the folio ving possible consequences and/or complications may result because of my refusal to accept trea ment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and f llowing my expressed wishes and directions. 7-24-2019 Counseled by Date Pa nt's Sign Date / -," r //re-ce" NYM--NEW YORK MCC (SONY 00001017 EFTA_0000022 EFTA00134761 BP-A0618 A&O DENTAL EXAMINATION JUN 16 (Initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Occlusion: • 2 3 4 5 8 7 8 9 10 11 32 31 Gc4 30 29 28 27 26 25 24 23 22 110 1213 14 15 15 21 20 19 18 I? 4 1 in' :0 Oral Hygiene: Good FNr CPiTN: 3 3 2- 9 Head & Neck / Soft Ticsee• a m: I F: Classification: CLIC Pa'n Scale: Dental Prostheses at Intake: Yes No Typo: Age: Condition: Come" r -M. -to n.02 SS, Laie-d- a........‘O9 ad anc rl, i1A pixer A' ifil5 / I on Dlo Se/1)4— or can,3danc cderSCAteg Infra-oral Photos Taken: . Yes 0 Radiographs Taken: (Document findings cn ASO encounter) Yes 3 • Instructed how to obtain urgent and non-urgent dental care: Yes: I No: Treatment Priorities: None: Non-urgent non-urgent Urgent Re5arred to Sick Cal Radiographs authorized: PM: Prephylaxis authorized: Yes I No (Approval va-xl 18 months from examination date) I Burs Panorex Pa nt Name: sejn, "re_cci-tv E Dentist Signature: el 1:144-4.44LAAL S11)gnt;t7rre IscNumber: ig 74, I 3 l e= os-1/4\ Institution: / MCC NEW YORK Date: 7-* 2 6 —1 9. 8 latk/Stamp: C. Ancrum DDS. PDF Prescnbed by P6403 et en cer MCC New York Replaces NP-A0818 of JUN 10 13NY_00001018 EFTA_00000117 EFTA00134762 BP4,0618 JUN 18 U.S. DEPARTMENT OF JUSTICE A&O DENTAL EXAMINATION (Initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS Ocduslon: ■ 1 2 3 4 6 6 7 $ 0 10 11 12 13 14 15 16 a32 31 313 29 27 2825 21 23 22 21 20 19. 18 17 (AL fy Nt I F: Li Pain Scale: Oral Hygiene: Good CPITN: 3 2- 3 Head & Neck Soft Tissue: Cla ificattOn: CL- -T- /10 Dental Prostheses et Intake: Yes No Typo: Age: Codition: CpcTrantit 4O it 02 SS / Let-i-e-r C,...-‘,Aci Al feeecV ' )/2511•14, 1 SeiV-e- on C4r) inc 0 cst" Cityytd. .19Se-file4 Inha-oral Photos Taken: Yes 0 Radiographs Taken: (Document findings on A&O encounter) Yes 9 . Instructed how to cbtaLn urgent and non-urgent dental care: Yes: I No: Treatment Pnortes: None: Non-urgent non-urgent Urgent Referred to Sick Cail: Radiographs PM: BWs Panore:c authorized: ' Prophylaxis authortzed: Yes I No (Approval valid 10 months from examination date) Patient Natra: , ,..-itit &kmi Dec-R--e_v £ Dentis -1 9. ITins E Nanbet: -76 LI-s r 3 i SC Us-`s Institution: / MCC NEW YORK Date: 7- 26 Signature Block/Stamp: IDS. PDF Presented by P8400 et en a oruCer MCC New York Replaces BP-A0818 o1..UN 10 I i5 NY 0000[019 EFTA_00000228 EFTA00134763 SP-S358.060 MEDICAL TREATMENT REFUSAL COFFIM SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Fe eral Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental co dition, and release the Bureau of Prisons and its employees from any and all liability for respecting and f (lowing my expressed wishes and directions. 7-24-2019 Counseled by Dale Date NY 00003020 EFTA_00000229 EFTA00134764 Federal Bureau of Prisons U.S. Medical Center for Federal Prisons 1900 W. Sunshine Street Springfield, MO 65807 417-874-1621 ••• Sensitive But Unclassified "• Name EPSTEIN, JEFFREY Reg IS 76318-054 DOB 01/20/1953 Sex M Facility MCC New York Order Unit E06-547U Provider la filla MD Collected 07/09/2019 13:34 Received 07/10/2019 10:44 Reported 07/10/201914:46 LIS ID 188191004 HIV HIV 1/2 Negative Screening test - See confirmatory toeing (or Reactive results Negative FLAG LEGEND L=Low LI=Low Critical H=High Fil=-ligh Critical A=Abnormal Al =AbnorWl Critical Page 3 o13 SDNY_00001021 EFTA_00000230 EFTA00134765 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 4: 76118-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/10/2019 16:58 Provider: Lab Result Receive Facility: NYM Cosigned by on 07/14/2019 18:12. Bureau DI Risonr - NYM NY_00001022 EFTA_0000023 1 EFTA00134766 BP-S358.C,50 SEP 05 MEDICAL TREATMENT REFUSAL CDFRM U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that tho following possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. 7-242019 Counseled by Data Signature of Witne s Date (77--cre NYM-NEW YORK MCC Date } ONY_00001023 EFTA _OOOOOth EFTA00134767 SP-A0618 JUN 18 U.S. DEPARTMENT OF JUSTICE A&O DENTAL EXAMINATION (Initial Clinical Dental Findings) FEDERAL. BUREAU OF PRISONS Occluslorr 1 2 3 4 6 6 7 9 9 1011 1213 14. 15 19 32 31 30 29 28 27 28 25 2123 22 21 20 19 . 18 17 crg, Oral Hyg!ene: Good Fair . .1•W Craw: 3 3 3 2- Head 8 Neck / Soft Tissue: cr„ F: Classification: CL_ er Pain Scale: /la Dental Prostheses at tilts/ex Yes TYPe: Age: Condlton: CAM 42 CC Le SS i La...)-f—år O--,..l a Ic.is aka on DiciSeni -e- • er Ceb-OaS, ?Ai CdoS8-Aied Intra-erel Photos Taken: Yes 0 Radiographs Taken: (Document folding on A&0 encounkr) Yes g Instructed how to obtain urgent and non-urgent dental we: Yes: I No: Treatment Prtoades: None: Non-urgent non-urgent Urgunt Referred to Sick Colt Radiographs authorized: PM. . Prophylaxis authorizect Yes I No (Approval var 18 months from examination date) BW5: Panorox :ga t Narrar. , 9 SA.C.4 O -5;SV7 -42_ti 2- D ' I alur : 1)17-5 istur Number: i I \ Institution: / MCC NEW YORK Date: 7 .- 74 -19. /Stamp: 'DS. PI> PeescrIbed by P64C0 et en cer MCC New York • Replaces BP-A0818 atJUN 10 SONY 00001024 EFTA_00000233 EFTA00134768 SE SP-S.158 05 .060 MEDICAL TREATMENT REFUSAL COFRM P U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and hollowing my expressed wishes and directions. 7-24-2019 Counseled by Dale /fo NYM-NEW YORK MCC 1 DNY 00001025 EFTA_00000234 EFTA00134769 BP-S358.C60 MEDICAL TREATMENT REFUSAL CDFRM SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-10-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: 66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR. The following treatments) was/were recommended: CHEST X-RAY Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: WORSENING THE CONDITION IF THERE IS ANY FINDINGS I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and Its employees from any and all liability for respecting and following my expressed wishes and directions. RAY 7-10-2019 r\ t Counseled by Date Patien Signature Date Signature of Witness Date NYM—NEW YORK MCC ONY_00001026 EFTA_00000235 EFTA00134770 •• ••. •••••••• •••mm. BP-A0618 A&O DENTAL EXAMINATION JUN 18 U.S. DEPARTMENT OF JUSTICE • • • (Initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS Occlusion: I 2 3 4 5 8 7 8 0 10 11 1213 14. 15 11 -(2 32 31 30 29 20 27 2825 2423 22 21 20 IS • 18 17 Oral Hygiene: Good Fair Zoo r CPITN: 3 3 2- 2 Head & Neck / Soft Tissue: 0: C 7 P / L i Classification: CL- rn" Pain Scale: /10. Dental Prostheses at Intake: Yes No Type: fi e" Condition: ;orf Comm 4O r-to2ssion La L i o - Cl: 4f1 jr -5 obsefue• • 11 X41 o/ (.0,4.1m plosepie4 InUe-oral Photos Taken: Yes 0 Ftadlogmphs Taken: (Document findings on A&O encounter) Yes No • Insinxted how to obtain urgent and nan-agent dental ease: Yes: 1 ( NC Treatment Priciffes: None: Ncn-tugent non-urgent Urgent Referred to Sick Cal Radiographs authorized: PAs: . . Prophylaxis authorized: Yes i No (Approval valid 18 months from examination date) BWs: Panorax Pa ' nt Name: SC.,/ r) i ---) Cc -Pt ti E r)Ds F '4 7Nurnber. I -7(2 3 I Ce- OS-9 InstItiAlon: / MCC NEW YORK Date: 7-20 -I 9. Signature Bto ic/Stamp: DS. PDF Resorbed by P64410 Chle1 Dentg cer MCC New York ' • Replaces BP-P0618 01JUN 10 SONY 00001027 EFTA_00000236 EFTA00134771 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 08/10/2019 07:25 Sex: M Race: WHITE Provider. Reg #: 76318-0 Facility: NYM RN Unit: Z04 Emergency Code - Resuscitation Event encounter performed at Special Housing Unit. SUBJECTIVE: Emergency Note Provider: RN Team Members: Provider RN Team/Code Leader Code Events: IYM CPR Value Compressions EKG/Monitor Lifepak No shock advised CPR Compressions Oxygen 15 L IV Access Peripheral IV 18 g Left AC Airway Endotracheal Tube ET Tube 7.5 24CM to L Lip line Placed by Paramedics Medications Epinephrine 1mg IV Epinephrine 3 doses and Sodium bicarb 2 doses administered CPR Compressions Medications Sodium Bicarbonate 1 mEa/kg IV IV Fluids Normal Saline 0.9% 1000 ml Medications Epinephrine 1mg IV CPR Compressions Medications Sodium Bicarbonate 1 mEa/kg IV Medications Epinephrine 1mg IV CPR Compressions Comments: Date 08/10/2019 06:35 08/10/2019 06:39 08/10/2019 06:40 08/10/2019 06:47 08/10/2019 06:48 08/10/2019 07:08 08/10/2019 07:10 by paramedics 08/10/2019 07:11 08/10/2019 07:11 08/10/2019 07:12 08/10/2019 07:13 08/10/2019 07:14 08/10/2019 07:14 08/10/2019 07:18 08/10/2019 07:17 Responded to a body alarm at 0635 for medical emergency on 9S, Upon arrival Inmate was received o the floor of his cell unresponsive with CPR in progress by correctional officers, Inmate was Cold, with circumferential B ising around the neck and posterior mottling, Pupils Fixed and dilated, No Palpable pulses. Call place for EMS, CPR timed, AED Placed No shock advised, CPR Continued, inmate transported to HSU treatment room with CPR in pro ress, 18g hep lock to L AC, O2 15 Lt ViA BVM, Pulse Check NO SHOCK advised. EMS and Paramedics arrived 0656, Pla ed on cardiac monitor asystole Resumed CPR, Inmate was intubated by Medics, 3 Rounds of Epinephrine administered. Pulse Check asystole, Inmate was transported to Local ER with CPR in progress. OBJECTIVE: Exam: General Appearance Yes: Unconscious Generated 69110/2019 08:10 by RN Bureau of Prisons - NYM Pap 1 of 2 SDNY_00001028 EFTA_00000237 EFTA00134772 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: ISSIII ITE Facility: NYM Encounter Date: 08110/2019 07:25 Provider: RN Unit: Z04 Exam: ASSESSMENT: Cardiac Arrest PLAN: New Consultation Requests: Consultation/Procedure Emergency Room 08/10/2019 08/10/2019 Emergent Subtype: AMBULANCE Reason for Request: Cardiac arrest with CPR in progress Copay Required:No Cosign Required: Yes TelophoneNerbal Order: No Completed b RN on 08/10/2019 08:10 Requested to be cosigned by Cosign documentation will be displayed on the following page. larSethate Scheduled Target Date Priority Translator Language No Generated 08110/2018 08:10 by RN Bureau of Prisons - /*NM NS 2 of 2 SONY 00001029 EFTA_00000238 EFTA00134773 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Facility: NYM Encounter Date: 07/30/2019 15:58 Provider Sex: Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT WAS REFERRED BY THE WARDEN FOR EVALUATION. PATIENT REPORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK HE ALSO REPORTS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STATES THE NUMBNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. HE DENIES RIGHT SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OR SWALLOWING. HE REPORTS NOCTURIA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. HE REPORTS ti OF KIDNEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEP APNEA AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HERE SINCE HE DIE NOT HAVE ACCESS T HI CPAP MAC INE. I INFORME DHIM THAT WE RECEIVED HIS CPAP MACHINE AND IT WILL BE GIVE TO HIM TONIGHT.. HE REPORT OTHER NON-MEDICAL ISSUES. STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Seen far clinic(s): Pulmonary/Respiratory, Orthopeclic/Rheumatology, Endocrine/Lipid OBJECTIVE: Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely III Nutrition No: Appears Obese Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR), Normal Si and S2 No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neurologic Generated 07/30/2019 03:12 by Beaudoten. MD Bureau of Paws NYM Noe I of 2 SDNY_00001030 EFTA_00000239 EFTA00134774 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: ISMS Encounter Date: 07(30/2019 15:58 Provider: Reg #: 76318-054 Facility: NYM Unit ZO1 Exam: Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0-27.9, adult, 26827 - Current ConsUpation, unspecified, K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hypedipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Precliabetes, R7303 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: 64 Medication INsulin REG - Human Indication: Prediabetes Discontinued Medication Orders: Medication. 122148-NYM Insulin Reg (10 ML) 100 UNITS/ML In) Order Data 07/30/2019 15:58 Order Date 07/30/2019 15:58 Discontinue Type: When Pharmacy Processes Discontinue Reason:new order written Indication: Copay Required: No TelephoneNerbal Order: No Completed by Cosign Required: No on 07/30/2019 18:12 Prescriber Order SLIDING SCALE Subcutaneously each morning x 7 day(s) Pill Line Only Prescriber Order Inject regular insulin subcuteneouslyi per sliding scale: twice daily "'airline"' for 7 days Generated 07/30/2019 16:12 by Bureau cr Prisons • NYM PlIel 2 of 2 DNY_00001031 EFTA_00000240 EFTA00134775 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 11:12 Provider: Reg ll: 76318-054 Facility: NYM Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT S REFERRED BY THE WARDEN FOR EVALUATION. PATIEN E RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO E RRR S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STAT BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. HE DENT SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING qpi,, AL. OWING. HE REPORTS-39 IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. HE REPORTS H NEY STONES. HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEW51 AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HEREt§ CE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE R Et A HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-ME STATES HE FEELS OTHERWISE Pain: Not Applicable UES. Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology, OBJECTIVE: Pulse: pate Time Rate Per Minute Location 07/30/2019 13:02 94 07/30/2019 09:40 88 Via Machine 07/30/2019 09:30 87 Via Machine Respirations: Date Time Rate Per Minute Provider 07/30/2019 09:30 NYM 12 Blood Pressure: Date Time Value Location • osition 07/30/2019 13:02 NYM 114/84 Loft Arm Standing 07/30/2019 09:40 NYM 125/60 Right Arm Standing 07/30/2019 09:30 NYM 108/86 Loft Arm Sitting SaO2: age Time Value(%1 Air Provider 07/30/2019 09:30 NYM 98 Room Air Weight: 2119 Time L.k Kg Waist Circum. Provider Cuff Size Oti Provider eaudouin, MD , Robeirt MD MD Generated 07/302019 14;05 by Bureau of PrisOln • NYM Page 1 of 3 SDNY_00001032 EFTA_0000024 1 EFTA00134776 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg ri: 76318.054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: Unit: Z01 Date Time 07/30/2019 09:30 NYM 194.2 88.1 OA Ku Waist Qircum Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distre ed. Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic. Disheveled, Unke Acutely III Nutrition No: Appears O Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR 1 and S2 No: M/R/G Musculoskeletal Tibia / Fibula Neurologic No: Edema Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current Constipation, unspecified, K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, R7303 - Current Sleep apnea. G4730 - Current PLAN: New Medication Orders: Rx Medication Order Date prescriber Order Generated 07/30/2019 14:05 by Bureau of Prisons • NYM Page 2 of 3 SD/47_00001033 EFTA_00000242 EFTA00134777 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 11:12 Provider: Now Medication Orders: Exit Medication Order Date Magnesium Hydroxide Susp cone 800 07/30/2019 11:12 MG/5ML Indication: Constipation. unspecified INsulin REG - Human 07/30/2019 11:12 Indication: Prediabeles Renew Medication Orders: Medication Order Date 121836-NYM methylPR ne 4 MG Tab ( 21 count 07/30/2019 11:12 Pack) Indication: 1 DzpTia and neuritis, unspecified New Laboratory Requests: Details Frequency Lab Tests - Short List-General-CBC w/dill no Time Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short List-General-Comprehensiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic New Radiology Request Orders: Details General Radiology-Spine / Cervical- General Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI PLEASE PERFORM C SPINE SERIES Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format 07/30/2019 Counseling Pro0kenta. One Time 07/30/2019 Counseling Plan of Care Copay Required:No Cosign Required: No TelephoneNerbal Order: No Completed by on 07/30/2019 14:05 Handout/Tel& Access to Care Reg #: 76318.054 Facility: NYM Unit: Z01 Prescriber Order 10 CC Orally - Two Times a Day PRN x 90 day(s) SLIDING SCALE Subcutaneously - Two Times a Day x 7 day(s) Pill Line Only prescriber Order Take the tablet by mouth as directed x 6 day(s) Due Date 08/01/2019 00:00 Due Date Priority Routine Priority 08/29/2019 Routine R 2-3 MINUTES 3 DAYS AGO. udg ii Provider 8eaudo caltOttle Verbalizes Understanding Verbalizes Understanding Generated 07/30/2019 14:05 by Bureau of Prisons • NYM Page 3 of 3 SONY _00001034 EFTA_00000243 EFTA00134778 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 11:12 Provider: Reg #: 76318.054 Facility: NYM Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed al Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT REFERRED BY THE WARDEN FOR EVALUATION. PATIEN gEpORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO AE eilt:RIS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STATES'S HE DENIE SPEAKING HE REPORT HE REPORTS H TOPROL. HE AHS A HX OF SLEEpApy AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HER CE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE R EL1tED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-ME ISSUES. STATES HE FEELS OTHERWISE Pain: Not Applicable BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. SIDED WEAKNESS, DIPLOPIA. FACIAL DROOP, DIFFICULTY ALLOWING. IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. DNEY STONES. FIX OF HTN FOR WHICH HE WAS TAKING Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology, OBJECTIVE: Pulse: 7) Pita Time Rate Per Minute Wallet) 07/30/2019 13:02 94 07/30/2019 09:40 88 Via Machine 07/30/2019 09:30 87 Via Machine Respirations: atilt Time Rate Per Minute aovider 07/30/2019 09:30 NYM 12 Blood Pressure: Dale i e Value Location Position 07/30/2019 13:02 NYM 114/84 Left Arm Standing 07/30/2019 09:40 NYM 125/60 Right Arm Standing 07/30/2019 09:30 NYM 108/86 Left Arm Silting espiratory provider eaudouin, Robert MD Baud MD ei Robert MO a Cuff Size Provider Robert MD Robert MD SaO2: aaia Time Value(%) Aft Provider 07/30/2019 09:30 NYM 98 Room Air Weight: QalA Time Lba Kg Waist Circum, Proviskr. Generated 07/30/2019 14:05 by Buleau of Prisons • NYM Page 1 of 3 SONY 0000103S EFTA_00000244 EFTA00134779 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 11:12 Provider: Reg ti: 76318.054 Facility: NYM Unit: Z01 !Tats Time 07/30/2019 09:30 NYM 194.2 88.1 Lin .K.9 Waist Circum Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distre ed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unke cutely III Nutrition No: Appears O Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neu rolog lc Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: v/Wel le5and S2 Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current Constipation, unspecified, K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, R7303 - Current Sleep apnea, 64730 - Current PLAN: New Medication Orders: fig Medication Order Date Proscriber Order Generated 07130/2019 14:05 by Bureau of Prisons - NYM Page 2 01 3 SDNY_00001036 EFTA_00000245 EFTA00134780 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 11:12 Provider: Reg it: 76318.054 Facility: NYM Unit: 201 Now Medication Orders: Siff Magnesium Hydroxide Susp cone 800 MG/5ML Indication: Constipation, unspecified INsulin REG - Human Indication: Prediabetes Renew Medication Orders: Exit MedicatiOrt Order Dale, Proscriber Order 121836-NYM methylPR o ne 4 MG Tab ( 21 count 07/30/2019 11:12 Take the tablet by mouth as Pack) directed x 6 day(s) Indication: iTh 1tt, is and neuritis, unspecified New Laboratory Requests: Details V Frequency Due Date Priority Lab Tests - Short List-General-CBC w diff Time 08/01/2019 00:00 Routine Lab Tests-P-PSA, Total Lab Tests-U-Uric Add Lab Tests - Short List-General-Comprehensiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic New Radiology Request Orders: Details Frequency Due Date. Priority General Radiology-Spine / Cervical- One Time 08/29/2019 Routine General Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI R 2-3 MINUTES 3 DAYS AGO. PLEASE PERFORM C SPINE SERIES Order Date 07/30/2019 11:12 07/30/2019 11:12 Prescriber Order 10 CC Orally - Two Times a Day PRN x 90 day(s) SLIDING SCALE Subcutaneously - Two Times a Day x 7 day(s) Pill Line Only Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Pate Initiated Format 07/30/2019 Counseling Handout/Topic Access to Care 07/30/2019 Counseling Plan of Care Copay Required:No Cosign Required: No TelephoneNerbal Order: No Completed by on 07/30/2019 14:05 ry yiste:r I:10room Verbalizes Understanding Verbalizes Understanding Generated 07/30/2019 14:05 by Bureau ol Pascoe • NYM P:190 3 of 3 SDNY00001037 EFTA_00000246 EFTA00134781 Bureau of Prisons Health Services See Amendment Irmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 15:58 Facility: NYM Amendment made to this noto by on 07/30/2019 16:12. Bunaau of Prisons • NYM SDNv_00001038 EETA_00000247 EFTA00134782