EFTA00138991.pdf

Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 08/10/2019 07:25 Provider: RN Unit: Z04 Emergency Code - Resuscitation Event encounter performed at Special Housing Unit. SUBJECTIVE: Emergency Note Provider: Team Members: Provider RN Bole Team/Code Leader RN Code Events: IYRe Value Date CPR Compressions 08/10/2019 06:35 EKG/Monitor Lifepak 08/10/2019 06:39 No shock advised CPR Compressions 08/10/2019 06:40 Oxygen 15 L 08/10/2019 06:47 IV Access Peripheral IV 08/10/2019 06:48 18 g Left AC Airway Endotracheal Tube ET Tube 7.5 24CM to L Lip line Placed by Paramedics 08/10/2019 07:08 Medications Epinephrine 1mg IV 08/10/2019 07:10 Epinephrine 3 doses and Sodium bicarb 2 doses administered by paramedics CPR Compressions 08/10/2019 07:11 Medications Sodium Bicarbonate 1 mEa/kg IV 08/10/2019 07:11 IV Fluids Normal Saline 0.9% 1000 ml 08/10/2019 07:12 Medications Epinephrine 1mg IV 08/10/2019 07:13 CPR Compressions 08/10/2019 07:14 Medications Sodium Bicarbonate 1 mEa/kg IV 08/10/2019 07:14 Medications Epinephrine 1mg IV 08/10/2019 07:16 CPR Compressions 08/10/2019 07:17 Comments: Responded to a body alarm at 0635 for medical emergency on 9S, Upon arrival Inmate was received on the floor of his cell unresponsive with CPR in progress by correctional officers, Inmate was Cold, with circumferential Bruising around the neck and posterior mottling, Pupils Fixed and dilated, No Palpable pulses, Call place for EMS, CPR Continued, AED Placed No shock advised, CPR Continued, inmate transported to HSU treatment room with CPR in progress, 18g hep lock to L AC, O2 15 Lt ViA BVM, Pulse Check NO SHOCK advised. EMS and Paramedics arrived 0656, Placed on cardiac monitor asystole Resumed CPR, Inmate was intubated by Medics, 3 Rounds of Epinephrine administered, Pulse Check asystole, Inmate was transported to Local ER with CPR in progress. OBJECTIVE: Exam: General Appearance Yes: Unconscious Generated 08/1012019 08:10 by RN Bureau of Prisons - NYM SDNY_0001:74564 1 of 2 EFTA00138991 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 08/10/2019 07:25 Provider: RN Unit: Z04 Exam: ASSESSMENT: Cardiac Arrest PLAN: New Consultation Requests: Consultation/Procedure Target Date Scheduled Target Date Priority Translator Language Emergency Room 08/10/2019 08/10/2019 Emergent No Subtype: AMBULANCE Reason for Request: Cardiac arrest with CPR in progress Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Completed by RN on 08/10/2019 08:10 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 08,10,2019 08:10 by RN Bureau of Prisons - NYM SDNY_0001-71.55 rage 201 2 EFTA00138992 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: 08/10/2019 07:25 Provider: RN Facility: NYM Cosigned by MD on 08/12x2019 08:09. Bureau of Pesons NYM SDNV_00017356 EFTA00138993 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 15:58 Provider: MD Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: MD Chief Complaint: Other Problem Subjective: PATIENT WAS REFERRED BY THE WARDEN FOR EVALUATION. PATIENT REPORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO REPORTS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STATES THE NUMBNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. HE DENIES RIGHT SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OR SWALLOWING. HE REPORTS NOCTURIA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. HE REPORTS H OF KIDNEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEP APNEA AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HERE SINCE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE RECEIVED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-MEDICAL ISSUES. STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Seen for clinic(s): Pulmonary/Respiratory, Orthopedic/Rheumatology, Endocrine/Lipid OBJECTIVE: Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely III Nutrition No: Appears Obese Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2 No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neurologic Generated 07/30/2019 16:12 by MD Bureau of Prisons - NYM SONY_0001-7257 raga 1 of 2 EFTA00138994 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 15:58 Provider: MD Reg #: 76318-054 Facility: NYM Unit: Z01 Exam: Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current Constipation, unspecified, K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, R7303 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: Eta Medication INsulin REG - Human Indication: Prediabetes Discontinued Medication Orders: Eta Medication 122148-NYM Insulin Reg (10 ML) 100 UNITS/ML lnj Order Date 07/30/2019 15:58 Order Date 07/30/2019 15:58 Discontinue Type: When Pharmacy Processes Discontinue Reason:new order written Indication: Copay Required:No Telephone/Verbal Order: No Completed by Cosign Required: No MD on 07/30/2019 16:12 Prescriber Order SLIDING SCALE Subcutaneously each morning x 7 day(s) Pill Line Only Prescriber Order Inject regular insulin subcutaneously per sliding scale: twice daily —*pill linen* for 7 days SDNY Generated 071302019 16:12 by _000 MD Bureau of Prisons - NYM 102 of 2 EFTA00138995 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 11:12 Provider: MD Reg #: 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 PATIE ALS STAT HE DEN SPEAKING HE REPORT HE REPORTS TOPROL. HE AHS A HX OF SLEEP ISNCE HE HASB EEN INFORME DHIM THAT WE HIM TONIGHT.. HE REPORT OTHER NON-ME STATES HE FEELS OTHERWISE Pain: Not Applicable MD REFERRED BY THE WARDEN FOR EVALUATION. RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY OWING. IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING AND STATED HE HAS NOT SLEPT FOR 3 WEEKS E HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I HIS CPAP MACHINE AND IT WILL BE GIVEN TO ES. OBJECTIVE: Pulse: Date 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 07/30/2019 09:30 NYM Rate Per Minute Provider 12 Blood Pressure: Date Time 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 Sitting SaO2: Date Time Value(%) Air 07/30/2019 09:30 NYM 98 Room Air Weight: Date Time )1 Cuff Size Provider Provider Lim Kg Waist Circum Provider MD D MD MD MD Generated 07/30/2019 14:05 by MD Bureau of Prisons - NYM SDNY_0001/01 of 3 Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology,4 Respiratory EFTA00138996 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 11:12 Provider: M Race: WHITE Reg #: 76318-054 Facility: NYM MD Unit: Z01 Date lime 07/30/2019 09:30 NYM 194.2 88.1 MD Lbs Kg Waist Circum. Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distr ed. Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unk 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 Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0.27.9, adult. Z6827 - Current Constipation, unspecified, K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, 87303 - Current Sleep apnea, G4730 - Current 1 and S2 PLAN: New Medication Orders: BXg Medication Order Date Prescriber Order 2 of 3 Generated 07)30,2019 14:05 by MD Bureau of Prisons - NYM SDNY_OOOWN EFTA00138997 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 11:12 Provider: MD Reg #: 76318-054 Facility: NYM Unit: Z01 New Medication Orders: fiat Medication Order Date Magnesium Hydroxide Susp conc 800 07/30/2019 11:12 MG/5ML Indication: Constipation, unspecified INsulin REG - Human 07/30/2019 11:12 Indication: Renew Medication Orders: Medication 121836-NYM methylP Pack) Indication: New Laboratory Requests: Details Frequency Lab Tests - Short List-General-CBC w diff one 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 NU PLEASE PERFORM C SPINE SERIES Prediabetes Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format 07/30/2019 Counseling 07/30/2019 Counseling Copay Required:No Telephone/Verbal Order: No Completed by ne 4 MG Tab ( 21 count Order Date 07/30/2019 11:12 a and neuritis, unspecified Frequency One Time Handout/Topic Access to Care Plan of Care Cosign Required: No MD on 07/30/2019 14:05 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 08/29/2019 Priority Routine Priority Routine R 2-3 MINUTES 3 DAYS AGO. Outcome Verbalizes Understanding Verbalizes Understanding Generated 071302019 14:05 by MD Bureau of Prisons - NYM SDNY_00011613 of 3 EFTA00138998 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 11:12 Provider: MD Reg #: 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 PATIE ALS STAT HE DEN SPEAKING HE REPORT HE REPORTS TOPROL. HE AHS A HX OF SLEEP ISNCE HE HASB EEN INFORME DHIM THAT WE HIM TONIGHT.. HE REPORT OTHER NON-ME STATES HE FEELS OTHERWISE Pain: Not Applicable MD REFERRED BY THE WARDEN FOR EVALUATION. RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY OWING. IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING AND STATED HE HAS NOT SLEPT FOR 3 WEEKS E HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I HIS CPAP MACHINE AND IT WILL BE GIVEN TO ES. Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology0 Respiratory 0 OBJECTIVE: Pulse: Date lime 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 07/30/2019 09:30 NYM Rate Per Minute Provider 12 Blood Pressure: Data lime 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 Sitting SaO2: Data lima 07/30/2019 09:30 NYM Weight: Date Time Cuff Size Provider Value(%) Air Provider 98 Room Air Lin Kg Waist Circum. Provider MD MD MD MD MD MD MD Generated 071302019 14:05 by MD Bureau of Prisons - NYM SDNY_0001-7382 rage-1 of 3 EFTA00138999 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 11:12 Provider: M Race: WHITE Reg #: 76318-054 Facility: NYM MD Unit: Z01 Date Time 07/30/2019 09:30 NYM 194.2 88.1 MD Lbs Kg Waist Circum. Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distr ed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unk 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 Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0.27.9, adult, Z6827 - Current Constipation, unspecified, K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, 87303 - Current Sleep apnea, G4730 - Current 1 and S2 PLAN: New Medication Orders: Hxg Medication Order Date Prescriber Order Generated 07/3012019 14:05 by MD Bureau of Prisons - NYM SDNY_0001-7383 rage 2 of 3 EFTA00139000 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 11:12 Provider: MD Reg #: 76318-054 Facility: NYM Unit: Z01 New Medication Orders: fiat Medication Order Date Magnesium Hydroxide Susp conc 800 07/30/2019 11:12 MG/5ML Indication: Constipation, unspecified INsulin REG - Human 07/30/2019 11:12 Indication: Renew Medication Orders: 13att Medication 121836-NYM methylP Pack) Indication: New Laboratory Requests: Details Frequency Lab Tests - Short List-General-CBC w diff one 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 NU PLEASE PERFORM C SPINE SERIES Prediabetes Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format 07/30/2019 Counseling 07/30/2019 Counseling Copay Required:No Telephone/Verbal Order: No Completed by ne 4 MG Tab ( 21 count Order Date 07/30/2019 11:12 a and neuritis, unspecified Frequency One Time Handout/Topic Access to Care Plan of Care Cosign Required: No MD on 07/30/2019 14:05 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 08/29/2019 Priority Routine Priority Routine R 2-3 MINUTES 3 DAYS AGO. Outcome Verbalizes Understanding Verbalizes Understanding Generated 072302019 14:05 by MD Bureau of Prisons - NYM SDNY_000a3 of 3 EFTA00139001 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 15:58 Facility: NYM Amendment made to this note by MD on 07 30 2019 16:12. Bureau of Prisons • NYM SDNY_00017365 EFTA00139002 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: 07/28/2019 20:25 Provider: 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 stats " My R hand still has pins and needles sometimes" No change in appearance from previous exam. Pain: No OBJECTIVE: Pulse: Date lime Rate Per Minute Location Rhythm Provider 07/28/2019 20:28 81 RN Respirations: Dale Time Rate Per Minute Provider 07/28/2019 20:28 NYM 14 RN Blood Pressure: Date lime Value Location Position Cuff Size Provider 07/28/2019 20:28 NYM 157/91 RN SaO2: Dale BEM Valuer/O1 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 07/28/2019 20:30 by RN Bureau of Prisons - NYM SDNY_000W1 of 2 EFTA00139003 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/28/2019 20:25 Provider: RN Unit: H01 Follow-up in 12-24 Hours Patient Education Topics: Date Initiated Format Handout/Topic 07/28/2019 Counseling Plan of Care Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Completed by RN on 07'28'2019 20:30 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Provider Outcome Verbalizes Understanding Generated 0712&201920:30 by RN Bureau of Prisons - NYM SDNY_0001-7387 rage 2 of 2 EFTA00139004 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: 07/28/2019 20:25 Provider: RN Facility: NYM Cosigned by MD on 07 28 2019 20:50. ' Pr ',or, NYt! SDNV_00017368 EFTA00139005 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE 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 - Tingling/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 do" Pain: No OBJECTIVE: Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/28/2019 06:57 82 RN Respirations: Date Time Rate Per Minute Provider 07/28/2019 06:57 NYM 14 RN Blood Pressure: Date lime Value Location Position Cuff Size Provider 07/28/2019 06:57 NYM 138/80 SaO2: Date Time Valuerkl Air 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/Normocephalic No: Facial Asymmetry, Battle's Sign, Raccoon Eyes, Deformity Eyes General Yes: PERRLA, Extraocular Movements Intact RN RN Face General Yes: Symmetric Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM SDNY_00011491 of 3 EFTA00139006 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: RN Unit: H01 Exam: No: Ecchymosis, Numbness, Swelling, Periorbital 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 WrisVHand/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) R, Contusion(s) R ROS Comments Received inmate AAOX3 in no acute distress, speaking in full sentenced ambulating independently CIO Right arm 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 ecchymosis noted. Denies any pain numbness or tingling at this time. Denies any Chest pain, Headache, Dizziness, SOB or Blurred vision. Eyes PERRLA. 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: Date Initiated Format Handout/Topic Provider Outcome 07/28/2019 Counseling Plan of Care Verbalizes Understanding Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM SDNY_0001:7422 of 3 EFTA00139007 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: RN Unit: H01 Date Initiated Format HandouUTqpic Provider Outcome Copay Required:No Telephone/Verbal Order: No Completed by RN on 07/28/2019 07:22 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Cosign Required: Yes Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM SDNY_000'1:7413 of 3 EFTA00139008 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: 07/28/2019 06:51 Provider: RN Facility: NYM Cosigned by MD on 07.28.2019 20:51. ' Pr sae; NYt.' SDNV_00017372 EFTA00139009 Copay Required:No Telephone/Verbal Order: No Completed by Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: Date of Birth: Note Date: EPSTEIN. JEFFREY EDWARD 01/20/1953 07/26/2019 08:57 Sex: Provider: M MD Reg #: Facility: Unit: 76318-054 NYM H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. New Medication Orders: SX Medication Docusate Sodium Capsule Indication: Constipation, unspecified Cosign Required: No MD on 07/26/2019 08:58 Order Date 07/26/2019 08:57 Prescriber Order TAKE ONE 100 MG CAP Orally - Two Times a Day x 180 day(s) Generated 07.262019 08:58 by MD Bureau of Prisons - NYM SDNY_OOPOW1)3°I EFTA00139010 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: • Facility: NYM Note Date: 07/24/2019 16:10 Provider: MD Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. Copay Required:No Telephone/Verbal Order: Completed by Cosign Required: No 24/2019 16:12 Generated 07/24/2919 16:12 by MD Bureau of Prisons - NYM soNcooPoiVe EFTA00139011 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Rarp.WHITF Note Date: 07/24/2019 16:10 Provider: Reg #: 76318-054 Facility: NYM MD Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. Copay Required:No TelephoneNerbal Order: Completed by I Cosign Required: No 24/2019 16:12 Generated 07/24/2919 16:12 by MD Bureau of Prisons - NYM SDNY_OOPOWe f 1 EFTA00139012 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 by MD on 07 26 2019 08:58. Bureau of Prisons • Nym SDNY_00017376 EFTA00139013 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Facility: NYM Note Date: 07/24/2019 15:10 Provider: 1WISM MD Unit: H01 Admin Note - General Administrative Note encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD PATIENT WAS OFFERED TO HAVE AN OPTOMETRIST EVALUATION. HE REFUSED. REFUSAL FORM SIGNED. Copay Required:No TelephoneNerbal Order: No Completed by Cosign Required: No MD on 07/24/2019 15:17 Generated 07/24/2919 15:17 by MD Bureau of Prisons - NYM SDNY_OOPOWV7°f 1 EFTA00139014 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: 07/24/2019 13:08 Provider: MLP Unit: H01 Mid Level Provider - Follow up Visit encounter performed at Receiving & Discharge. SUBJECTIVE: COMPLAINT 1 Provider: . MLP 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: Date Time Fahrenheit Celsius Location Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral MLP Pulse: Dale Time Rate Per Minute Location Rhythm Provider 07/24/2019 13:12 83 Via Machine Regular . MLP Blood Pressure: Date Time Maim Location Position Cuff Size Provider 07/24/2019 13:12 NYM 132/89 Right Arm Sitting Adult-regular MLP SaO2: Date Time Value(%) Ai_► Provider 07/24/2019 13:12 NYM 96 Room Air MLP Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Appears in Pain Exam 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 does not complaint of any respiratory problem or distress. He still does not want to explain how the skin injury on his neck happed. he insinuates that injuries on his neck have to do with his room mate. But does not want to talk about it. ASSESSMENT: Injury, unspecified, T1490 - Current PLAN: Disposition: Generated 07/24/2019 13:24 by MLP Bureau of Prisons - NYM SDNY_0001-7379 raya 1 of 2 EFTA00139015 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/24/2019 13:08 Provider: . MLP Unit: H01 Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format Handout/Topic ii. Outcome 07/24/2019 Counseling Access to Care . Verbalizes Understanding 07/24/2019 Counseling Preventive Health Verbalizes Understanding Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Completed by . MLP on 07/24/2019 13:24 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. SDNY Generated 07124/2019 13:24 by _0001-7379 MLP Bureau of Prisons - NYM raga 92 of 2 EFTA00139016 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: 07/24/2019 13:08 Provider: MLP Facility: NYM Cosigned with New Encounter Note by MD on 07/24/2019 16:10. Bureau of Prisons NYM SDNY_00017380 EFTA00139017 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: MLP Unit: H01 Injury Assessment - Non-work related encounter performed at Health Services. SUBJECTIVE: INJURY 1 Provider: MLP Date of Injury: 07/23/2019 01:27 Date Reported for Treatment: 07/23/2019 08:25 Work Related: No Work Assignment: UNASSG Pain Location: Pain Scale: 0 Pain Qualities: Where Did Injury Happen (Be specific as to location): Special Housing Unit Z05-Cell 124 L Cause of Injury (Inmate's Statement of how injury occurred): "I do not know. Just went to drink a little water and wake up snorting". Symptoms (as reported by inmate): None OBJECTIVE: Temperature: Data Time Fahrenheit Celsius Location 07/23/2019 06:30 NYM 97.5 36.4 Oral Provider MLP Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/23/2019 06:30 92 Via Machine Regular . MLP Respirations: Data Time Rate Per Minute Provider 07/23/2019 06:30 NYM 16 MLP Blood Pressure: Data Time Value Location Position Cuff Size Provider 07/23/2019 06:30 NYM 140/85 Right Arm Sitting Adult-regular MLP SaO2: Date Time Value(%) Air Provider 07/23/2019 06:30 NYM 96 Room Air MLP Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Lethargic, Dyspneic, Appears in Pain, Pallor, Cyanotic, Diaphoretic, Disheveled, Generated 071231201909:05 by MLP Bureau of Prisons - NYM SDNY_0001-7391 raga 1 of 2 EFTA00139018 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: . MLP Unit: H01 Exam: Acutely III Pulmonary Auscultation Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally No: Crackles, Rhonchi, Wheezing Exam Comments Inmate for injury report as requested by Operational Lt. He is ambulatory, oriented x 3. In not apparent distress, smiling during this clinical encounter. Alleges, that he does not know what happened. Can not explain the marks on his neck. Responded: "I don't know". He does not want to talk of the events leading to the marks on his neck. He does not look in any distress or pain. Has an circular line of erythema at the base of the neck. Reaching 2/3 of the neck circumference, 2 inches wide, sparing the back of the neck. Has one section of this erythema in the front with marks of friction. No inflammation, no deformities, no hematomas, no lacerations, no tenderness. Patient moving his neck without any restriction. Denies having any pain or discomfort. Denies any respiratory problem. Has another small erythema on left knee about 2cm in diameter(mild). As per information from custody staff inmate Epstein was found in his cell with a rope around his neck and sitting on the floor. Inmate is currently placed on suicide watch. ASSESSMENT: Injury, unspecified, T1490 - Current - R/O self inflicted injuries. PLAN: Disposition: Follow-up at Sick Call as Needed Placed on Suicide Watch Follow-up in 2-4 Hours Other: For follow up with psychology service. Patient Education Topics: Date Initiated Format Handout/Topic MI. 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 Telephone/Verbal Order: No Completed by . MLP on 07/23/2019 09:05 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 07123 201909.05 by MLP Bureau of Prisons - NYM SDNY_0001-739 ag2 re -2 of 2 EFTA00139019 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/23/2019 06:20 Provider: MLP Facility: NYM Cosigned by MD on 07/23/2019 15:44. Bureau of Prisons NYM SDNY_00017383 EFTA00139020 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/14/2019 17:36 Provider: MD Unit: Z05 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: MD Chief Complaint: ENDO/LIPID Subjective: 66 YR OLD WHITE MALE WITH HX OF HYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , NOW 431. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS DUE TO THEIR GI SIDE EFFECTS. HX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE FBI LOKELY HAS L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES. SURGICAL HX: NONE MENTAL HEALTH HX: NONE Pain: Yes Pain Assessment Date: 07/12/2019 13:25 Location: Back-Middle Quality of Pain: Shooting Pain Scale: 5 Intervention: MEDROL DOSE PACK Trauma Date/Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: Seen for clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid Added to clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid OBJECTIVE: Exam: General Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely III Nutrition No: Appears Obese Generated 07/14/2019 18:11 by MD Bureau of Prisons - NYM SDNY_00011464 1 of 3 EFTA00139021 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Ar il ivr/lHITE Encounter Date: 07/14/2019 17:36 Provider: MD Reg #: 76318-054 Facility: NYM Unit: Z05 Exam: Eyes General Yes: PERRLA, Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR), Normal St and S2 No: M/R/G Abdomen Auscultation Yes: Normo-Active Bowel Sounds Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back Yes: Tenderness Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam ASSESSMENT: Constipation, unspecified, K5900 - Current Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: JIM Medication Omega 3 ( Vascepa) 1 GM Capsule Order Date 07/14/2019 17:36 Indication: Hyperlipidemia, unspecified New Laboratory Requests: Details Frequency Lab Tests-H-Hemoglobin A1C One Time Lab Tests-L-Lipid Profile Additional Information: Generated 07/14;2019 18:11 by MD Bureau of Prisons - NYM Prescriber Order TAKE 2 CAPS Orally - Two Times a Day x 180 day(s) -- TAKE WITH FOOD. Due Date Priority 10/10/2019 00:00 Routine SDNY_00047rog 18852 of 3 EFTA00139022 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Reg #: Facility: 76318-054 NYM Encounter Date: 07/14/2019 17:36 Provider: MD Unit: 205 FASTING. Lab Tests-H-Hep B surface Ab One Time 08/08/2019 00:00 Routine Lab Tests-H-Hep B surface Ag Lab Tests-H-Hep C Ab Lab Tests-H-Hepatic Profile Schedule: Activity Date Scheduled Clinical Encounter 07/24/2019 00:00 66 YR OLD MALE FOR ROUTINE SCREENING. Chronic Care Visit 01/07/2020 00:00 6 MONTH F/U. Chronic Care Visit 07/01/2020 00:00 Other: PENDING EKG AND FOBT. CXR WAS REFUSED. Patient Education Topics: Date Initiated Format 07/14/2019 Counseling Copay Required:No Telephone/Verbal Order: No Completed by Handout/Topic Diagnosis Cosign Required: No MD on 07/14/2019 18:11 Scheduled Provider Optometrist Mid-Level Provider Physician 01 Provider Outcome Verbalizes Understanding Generated 07/14/2019 18:11 by MD Bureau of Prisons - NYM SDNY_000R193 of 3 EFTA00139023 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: MD Unit: Z05 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDO/LIPID Subjective: 66 YR O HITE MALE WITH HX OF HYPER CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MED • EIR GI SIDE EFFECTS. HX OF 4L UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES TH Y HAS L4 - L5 SEVERE iSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREM SURGICAL HX: NONE MENTAL HEALTH HX: Pain: Yes Pain Assessment Date: 07/12/2019 13:25 Location: Back-Middle Quality of Pain: Shooting Pain Scale: 5 Intervention: MEDROL DOSE PACK Trauma Date/Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: MD Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology OBJECTIVE: Exam: General Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely III Nutrition No: Appears Obese Generated 07/12/2019 14:20 by MD Bureau of Prisons - NYM SDNY_0001-7187 raga 1 of 3 EFTA00139024 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: Z05 Exam: Eyes General Yes: PERRLA, Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal SI and S2 No: M/R/G Abdomen Auscultation Yes: Normo-Active Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back Yes: Tenderness Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General ASSESSMENT: Constipation, unspecified, 1(5900 - Current ( N ) Yes: Normal Exam Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: Mit Medication Order Date Prescriber Order Magnesium Hydroxide Susp 07/12/2019 13:10 30 CC Orally - Two Times a Day PRN x 2 day(s) Indication: Constipation, unspecified MethyIPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 AS DIRECTED Orally - daily x Pack 21 tab) 6 day(s) Indication: Neuralgia and neuritis, unspecified Disposition: Generated 07/1232019 14:20 by MD Bureau of Prisons - NYM SDNY_00047308 rage 2 of 3 EFTA00139025 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: Z05 Follow-up at Sick Call as Needed Other: WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP. Patient Education Topics: Date Initiated Format Handout/Topic 07/12/2019 Counseling Diagnosis Copay Required:No Telephone/Verbal Order: Completed by Beaudouin, Cosign Required: No 07/12/2019 14:20 0 Provider Outcome Verbalizes Understanding Generated 07/1232019 14:20 by MD Bureau of Prisons - NYM SDNY_0001493 of 3 EFTA00139026 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: MD Unit: Z05 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDO/LIPID Subjective: 66 YR O HITE MALE WITH HX OF HYPER CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MED • EIR GI SIDE EFFECTS. HX OF UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES TH Y HAS L4 - L5 SEVERE iSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREM SURGICAL HX: NONE MENTAL HEALTH HX: Pain: Yes Pain Assessment Date: 07/12/2019 13:25 Location: Back-Middle Quality of Pain: Shooting Pain Scale: 5 Intervention: MEDROL DOSE PACK Trauma Date/Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: MD Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology OBJECTIVE: Exam: General Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely III Nutrition No: Appears Obese of 3 Generated 07/12/2019 14:20 by MD Bureau of Prisons - NYM SONY_00011499 EFTA00139027 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: Z05 Exam: Eyes General Yes: PERRLA, Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal SI and S2 No: M/R/G Abdomen Auscultation Yes: Normo-Active 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 4 2 1 % 0 Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current 1), Sleep apnea, G4730 - Current PLAN: New Medication Orders: Eta Medication Order Date Prescriber Order Magnesium Hydroxide Susp 07/12/2019 13:10 30 CC Orally - Two Times a Day PRN x 2 day(s) Indication: Constipation, unspecified MethyIPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 AS DIRECTED Orally - daily x Pack 21 tab) 6 day(s) Indication: Neuralgia and neuritis, unspecified Disposition: Generaled 07/1212019 14:20 by MD Bureau of Prisons - NYM SDNY_0001-739:1 rage 2 of 3 EFTA00139028 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: Z05 Follow-up at Sick Call as Needed Other: WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP. Patient Education Topics: Date Initiated Format Handout/Topic 07/12/2019 Counseling Diagnosis Copay Required:No Telephone/Verbal Order: Completed by Beaudouin, Cosign Required: No 07/12/2019 14:20 co Provider Outcome Verbalizes Understanding Generated 07/12/2019 14:20 by MD Bureau of Prisons - NYM SDNY_0001:70 3 of 3 EFTA00139029 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/14/2019 17:36 Facility: NYM Amendment made to this note by MD on 07/142019 18:11. Bureau of Prisons • NYM SDNY_00017393 EFTA00139030 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: Date of Birth: Note Date: EPSTEIN, JEFFREY EDWARD 01/20/1953 07/12/2019 09:06 Sex: Provider: 1 MD Reg #: Facility: Unit: 76318-054 NYM Z05 Admin Note - Orders encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD PATIENT REQUESTED TO HAVE A COLACE RX , INSTEAD OF TEH BISACODYL FOR CONSTIPATION. New Medication Orders: 13x# Medication Docusate Sodium Capsule Indication: Constipation, unspecified Discontinued Medication Orders: I324 Medication 121757-NYM Bisacodyl E.C. 5 MG TAB Order Date 07/12/2019 09:06 Order Date 07/12/2019 09:06 Discontinue Type: When Pharmacy Processes Discontinue Reason:discontinue Indication: Copay Required:No TelephoneNerbal Order: No Completed by Cosign Required: No MD on 07/12/2019 09:10 Prescriber Order TAKE ONE 100 MG CAP Orally - Two Times a Day x 30 day(s) Prescriber Order Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10 days Generated 07/12/2919 09:10 by MD Bureau of Prisons - NYM soNy_ooPoicIld4' 1 EFTA00139031 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Facility: NYM Note Date: 07/07/2019 00:17 Provider: 1 MD Unit: E06 Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MED CL:1 NO CCC APPT. MD Discontinued Laboratory Requests: Details Frequency Due Date Priority Lab Tests-H-Hemoglobin AlC One Time 08/05/2019 00:00 Routine Lab Tests-C-CBC w/diff Lab Tests-E.-Lipid Profile Lab Tests-C-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic Additional Information: 66 y/o male, elevated BP Labs requested to be reviewed by: MD New Laboratory Requests: !Malls 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 Date Due Date Priority General Radiology-Chest-2 Views One Time 07/25/2019 Routine Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR. Copay Required:No TelephoneNerbal Order: No Completed by Cosign Required: No MD on 07/07/2019 00:30 Generated 07/07/2019 00:30 by MD Bureau of Prisons - NYM soNv_ooPoi9M? 1 EFTA00139032 Bureau of Prisons Health Services Health Screen Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Seizures: Denied Diabetes: Denied Cardiovascular: Denied CVA: Denied Hypertension: Denied Respiratory: Denied Sickle Cell Anemia: Denied Carcinoma/Lymphoma: Denied Allergies: Denied PPD Administration: Date/Time: 07/06/2019 21:39 Provider: PA-C Location: Right Forearm Drug Mfg: Sanofi Pasteur Lot Number: C5474BA Dosage: 0.1mL Route: ID Exp Dt: 10/2020 Comments: Tuberculosis: Hx of Previous Disease: No Blood-tinged Sputum: No Night Sweats: No Weight Loss:No Fever: No Cough:No Comments: Generated 07/06/2019 21:56 by PA-C Bureau of Prisons - NYM SDNY _00017396 'Page 1 of 6 EFTA00139033 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Infectious Disease Risk Factors: IV Drug Use: No IV Drug Use Needles: Sexual Partner IV Drug Use: No Sexual Partner IV Drug Use Needles: Female Sexual Partners (Last 5 Yrs): 10+ Male Sexual Partners (Last 5 Yrs): 0 Condom Use: Sometimes Sexual Contact With HIV+ Individual: No Blood Product Transfusion: No Travel Outside US: Yes Tattoos: No Comments: Born in US High school diploma Banker Traveled to Paris x 3 weeks up until arrest No tattoos HIV History: When Tested: 2019 Test Result: Negative When Diagnosed AIDS: Last CD4: Comments: Hepatitis: Denied Other Infectious Diseases: Syphilis: No Syphilis Last Treatment: N/A Genital Warts: No Chlamydia: Yes Gonorrhea: No Herpes: No Chicken Pox: Yes Other: No Comments: Chlamydia in 2015, treated Chicken pox in childhood Abuse History: Denied Physical: No Emotional: No Sexual: No Comments: Denies Generated 07/06/2019 21:56 by PA-C Bureau of Prisons - NYM SONY _00017397 'Page 2 of 6 EFTA00139034 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Mental Health: Level of Consciousness: Alert and Oriented Psychomotor Activity: Normal General Appearance:Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Hx of Mental Health Treatment: None Hx of Head Injury: None Current Mental Health Treatment: No Current Mental Health Complaint: No Hx of Loss of Consciousness: No Fix of Hearing Voices: No Past History of Suicide Attempt: No Current Suicide Ideation: No Suicide Prevention Initiated:No Comments: Substance Use History: Denied Current Painful Condition: Denied Other Health Issues: Current Medical Conditions: Other Current Treatments: Pregnant: Dental Condition: Denied N/A Generated 07/06/2019 21:56 by PA-C Bureau of Prisons - NYM SDNY _00017398 'Page 3 of 6 EFTA00139035 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Observations: Draining Skin Lesions: No Signs of Lice: No Signs of Scabies: No Signs of Recent Trauma: No Recent Tattoos: No Needle Marks: No Signs of Rash: No Open Sores: No Wounds: No Body Deformities: No Tremors: No Sweating: No Comments: Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/06/2019 21:43 90 Via Machine PA-C Respirations: Date Time Rate Per Minute Provider 07/06/2019 21:43 NYM 15 PA-C Blood Pressure: Date lime Value Location Position Cuff Size Provider 07/06/2019 21:45 NYM 164/90 Right Arm Sitting Adult-regular PA-C 07/06/2019 21:43 NYM 155/83 Left Arm Sitting Adult-regular PA-C SaO2: Date Time Value(%) Air Provider 07/06/2019 21:43 NYM 95 Room Air PA-C Height: Date lime Inches Cm Provider 07/06/2019 21:43 NYM 72.0 182.9 PA-C Weight: Date Time Lbs Kg Waist Circum Provider 07/06/2019 21:43 NYM 200.0 90.7 PA-C Prosthetic Devices/Equipment: Denied Potential Items For Follow-up: Item Travel Outside US Other Infectious Disease History Comments: I have reviewed 0 pages of intake paperworks SDNY _0 9 Pa0ge 017 4 off 6 Generated 07/06/2019 21:56 by PA-C Bureau of Prisons - NYM EFTA00139036 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Health Problems Newly Identified During This Encounter: Health Problem Medication Reconciliation. The patient's known medication list including OTC items was compiled and compared to new and changed BOP orders. Reconciled Medications: Source Action Iyp.e BA Medication OTC No known OTCs Order Detail New Laboratory Requests: Details Frequency Due Date Priority Lab Tests-H-Hemoglobin A1C One Time 08/05/2019 00:00 Routine rlorty i Lab Tests-C-CBC w/diff Lab Tests-L-Lipid Profile Lab Tests-C-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic Additional Information: 66 y/o male, elevated BP Labs requested to be reviewed by: MD New Non-Medication Orders: Order Frequency Duration DeS6lls Ordered By EKG One Time 66 y/o male PA-C Order Date: 07/06/2019 Fecal Occult Blood One Time 3 different stools PA-C Order Date: 07/06/2019 Schedule: Activity Vision Screen 66 y/o male PPD Reading Follow-up BP check Date Scheduled Scheduled Provider 07/06/2019 00:00 Optometrist 07/08/2019 00:00 Nurse 07/09/2019 00:00 Mid-Level Provider Other: BP noticed to be elevated. IM denies Hx of HTN or any significant chronic medical conditions. He is currently asymptomatic and denies any bodily complaints at this time. Will recheck BP in 2-3 days. Disposition: Follow-up at Sick Call as Needed To be Evaluated by Provider Instructed inmate how to obtain medical, dental, and mental health care. Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Generated 07/06/2019 21:56 by PA-C Bureau of Prisons - NYM SONY _0001Z400 'Page 5 of 6 EFTA00139037 Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Completed by PA-C on 07/06/2019 21:56 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 07/06/2019 21:56 by PA-C Bureau of Prisons NYM SDNY _000114 -Page 6 of016 EFTA00139038 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA C Facility: NYM Cosigned with New Encounter Note by MD on 07/07/2019 00:17. Bureau of Prisons NYM SDNV_00017402 EFTA00139039 Bureau of Prisons Health Services History & Physical Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R e: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: . MLP Unit: H01 Seizures: Denied Diabetes: Denied Cardiovascular: Denied CVA: Denied Hypertension: Denied Respiratory: Denied Sickle Cell Anemia: Denied Carcinoma/Lymphoma: Denied Allergies: Denied Tuberculosis: Hx of Previous Disease: No Blood-tinged Sputum: No Night Sweats: No Weight Loss:No Fever: No Cough:No Comments: Infectious Disease Risk Factors: IV Drug Use: No IV Drug Use Needles: Sexual Partner IV Drug Use: No Sexual Partner IV Drug Use Needles: Female Sexual Partners (Last 5 Yrs): 10+ Male Sexual Partners (Last 5 Yrs): 0 Condom Use: Sometimes Sexual Contact With HIV+ Individual: No Blood Product Transfusion: No Travel Outside US: Yes Tattoos: No Comments: Born in US High school diploma Banker Traveled to Paris x 3 weeks up until arrest No tattoos SDNY_ 00017403 Generated 07/09/2019 13:03 by-. MLP Bureau of Prisons -P NYM age I of 13 EFTA00139040 Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: H01 HIV History: When Tested: 2019 Test Result: Negative When Diagnosed AIDS: Last CD4: Comments: Hepatitis: Denied Other Infectious Diseases: Syphilis: No Syphilis Last Treatment: N/A Genital Warts: No Chlamydia: Yes Gonorrhea: No Herpes: No Chicken Pox: Yes Other: No Comments: Chlamydia in 2015. treated Chicken pox in childhood Abuse History: Denied Physical: No Emotional: No Sexual: No Comments: Denies SDNY Inv 4(!.,)(1 13 Generated 07/09/2019 13:03 by-. MLP Bureau of Prisons NYM EFTA00139041 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R e: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: . MLP Unit: H01 Mental Health: Level of Consciousness: Alert and Oriented Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Hx of Mental Health Treatment: None Hx of Head Injury: None Current Mental Health Treatment: No Current Mental Health Complaint: No Hx of Loss of Consciousness: No Hx of Hearing Voices: No Past History of Suicide Attempt: No Current Suicide Ideation: No Suicide Prevention Initiated:No Comments: Substance Use History: Denied Current Painful Condition: Denied Other Health Issues: Current Medical Conditions: Other Current Treatments: Pregnant: Dental Condition: Denied N/A Generated 07/09/2019 13:03 by . MLP Bureau of Prisons • NYM SDNY _00017405 'Pa ge 3 of 13 EFTA00139042 Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: H01 Observations: Draining Skin Lesions: No Signs of Lice: No Signs of Scabies: No Signs of Recent Trauma: No Recent Tattoos: No Needle Marks: No Signs of Rash: No Open Sores: No Wounds: No Body Deformities: No Tremors: No Sweating: No Comments: SDNY 90017406 Generated 07/09/2019 13:03 by . MLP Bureau of Prisons NYM -Page 4 of 13 EFTA00139043 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R e: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: . MLP Unit: H01 Immunizations: Hepatitis A and B (TwinRx) Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Measles/Mumps/Rubella Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Smallpox Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Tetanus Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST SONY19404;1p3713 Generated 07;09/2019 13:03 by-. MLP Bureau of Prisons NYM EFTA00139044 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: H01 Immunization Date: Provider: MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Varicella Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Temperature: Date Time Fahrenheit Celsius Location Provider 07/09/2019 12:49 NYM 97.3 36.3 Oral . MLP Pulse: Dine Time Rate Per Minute Location Rhythm Provider 07/09/2019 12:49 82 Via Machine Regular MLP Respirations: that Time Rate Per Minute Provider 07/09/2019 12:49 NYM 16 . MLP Blood Pressure: Date Time Value Location Position Cuff Size Provider 07/09/2019 12:49 NYM 117/66 Right Arm Sitting Adult-regular MLP SaO2: Date lime Value(%) Air Provider 07/09/2019 12:49 NYM 97 Room Air MLP Height: Date lime Inches Cm Provider 07/09/2019 12:49 NYM 70.0 177.8 . MLP Generated 0710912019 13:03 by-. MLP Bureau of Prisons - NYM SDNY41m8,3 EFTA00139045 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R e: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: . MLP Unit: H01 Date Time inches Cm Provider Weight: Date Time the Kg Waist Circum. Provider 07/09/2019 12:49 NYM 194.4 88.2 . MLP Prosthetic Devices/Equipment: Denied Tobacco Usage: Denied General Social History: Foreign Travel: Born in USA: Yes Country of Birth: USA Patient Education Assessments: Date Ed Yrs Occupation Learns Best By Primary Language Barriers to Education 07/09/2019 12 Banker Speaking/Listening English None Family History - Father: Age at Death: 74 Cause of Death: Diabetes complications Significant Illnesses: Diabetes Heart Disease Comments: Family History - Mother: Age at Death: 81 Cause of Death: Kidney Failure Significant Illnesses: Heart Disease Comments: Family History - Sibling: Number of Siblings: 1 Significant Illnesses: Comments: Past Hospitalization: Reason Location When Acute Appendicitis Mount Sinai Hospital 1990 Complications: None Comments: Head: Normal: Yes Comments: Generated 07/09/2019 13:03 by MLP Bureau of Prisons • NYM SDNY_Fp29041;4i1f913 EFTA00139046 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R e: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: . MLP Unit: H01 Eyes: EOMI: Yes Icterus:No Conjunctival Inflammation: No Pupils PERRLA: Yes Pupil Size Rt: Pupil Size Lt: Pupils Comments: Fundi Vessels Nicking: No Fundi Vessels Discs Flat:Yes Fundi Vessels Discs Sharp Margins: Yes Fundi Vessels Grounds Abnormal: No Eyes Comments: Vision Screen 07/09/2019 12:52 Blindness: With Corrective Distance Vision: OD: 100 OS: 70 OU: OD: OS OU: Near Vision: OD: OS: OU: OD: OS: OU: Ishlhara 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: SDNY_0001Z410 Generated 07/09/2019 13:03 by Bureau of Prisons • WIN -Page a of 13 EFTA00139047 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: ,L Uace: WHITE Encounter Date: 07/09/2019 12:35 Provider: a. MLP Reg #: 76318-054 Facility: NYM Unit: H01 Mouth Lesions:No Oral/Buccal Mucosa:Yes Gums Normal: Yes Tonsils Present:Yes Tonsils Normal: Yes Pharynx: Normal Color Teeth Poor Dentition: No Teeth Count:Mostly Present Dentures: No Mouth Comments: Cranial Nerves: Intact II-XII: Yes Cranial Nerves Comments: Neck: Full ROM:Yes Masses/Nodes: No Trachea: Midline Thyroid: Normal Size Comments: Breasts: Normal: Yes Masses:No Tenderness: No Scars: No Dimpling:No Nipple Discharge: No Nipple Retraction: No Instructions for Self Breast Exam Given: No Comments: SDNY _00017411 Generated 07/09/2019 13:03 by MLP Bureau of Prisons • NYM 'Page 9 of 13 EFTA00139048 Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/09/2019 12:35 Provider l o af e:m MLP WHITE Reg 4: 76318-054 Facility: NYM Unit: H01 Thorax: Contour Normal:Yes Increased AP Diameter: No Asymmetrical Expansion:No Lungs Clear: Yes Wheezes: No Crackles: No Rhonchi: No Rales: No Accessory Muscle Use: No Comments: Spine: Deformity: No Full ROM:Yes Tenderness:No Comments: Cardiovascular: RRR: Yes Normal S1/S2: Yes Murmurs: No Carotid Bruits:No JVD: No Arteries: Bight Left Radial: Femoral: Dorsalis Pedls: Post. Tibialis: Comments: SDNYF4V164df213 Generated 07/09/2019 13:03 by-. MLP Bureau of Prisons NYM EFTA00139049 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: a gace: WHITE Encounter Date: 07/09/2019 12:35 Provider: MIIM MLP Reg #: 76318-054 Facility: NYM Unit: H01 Abdomen: Normal Contour:Yes Scaphoid: No Obese: No Gravid: No Hernias: No Bruits: No Masses:No Scars: No Tenderness: No Organomegaly: No Active Bowel Sounds: Yes Comments: Extremities: Nails Clubbing: No Nails Cyanosis: No Lower Extremity Edema - Right: None Lower Extremity Edema - Left: None Atrophy: No Amputations: No Other Deformities: No Varicosities:No Calf Tenderness:No Pulse Deficit: No Strength: Right 1.911 Arm: Leg: Full ROM: Bight Lett Arm: Yes Yes Leg: Yes Yes Comments: Generated 07/09/2019 13:03 by MLP SDNY4:17413 Bureau of Prisons • NYM 11 of 13 EFTA00139050 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: L Oace: WHITE Encounter Date: 07/09/2019 12:35 Provider: MLP Reg #: 76318-054 Facility: NYM Unit: H01 Reflexes: Right Left Biceps: Patellar: Brachloradialls: Achilles: Sensation: Vibratory: Yes Light Touch: Yes Pin Prick: Yes Comments: GU: Chaperoned By: Rectum: Not Done Comments: Refused. Male Genitalia: Not Done Comments: Refused. Skin: Normal: Yes Rash: No Redness:No Abnormal Pigmentation: No Abnormal Lesions/Growths: No Comments: Lymphatics: Adenopathy: Comments: No Potential Items For Follow-up: DOM 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. SDNY_000171 Generated 07/09/2019 13:03 by MLP Bureau of Prisons • NYM r' age 124o4f 13 EFTA00139051 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R e: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: . MLP Unit: H01 Cleared For Food Services: Yes Health Problems Newly Identified During This Encounter: Health Problem Constipation, unspecified - Current - New Medication Orders: Medication. Order Date Prescriber Order Bisacodyl E.C. Tablet 07/09/2019 12:35 5 mg Orally at bedtime PRN x 10 day(s) Indication: Constipation, unspecified Disposition: Follow-up at Sick Call as Needed Instructed inmate how to obtain medical, dental, and mental health care. Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Completed by MLP on 07/09/2019 13:03 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. SDNY41:17415 Generated 07/09/2019 13:03 by . Bureau of Prisons • NYM 13 Of 13 EFTA00139052 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/09/2019 12:35 Provider: MLP Facility: NYM Cosigned by MD on 07/11/2019 22:41. Bureau of Prisons NYM SDNY_00017416 EFTA00139053 Bureau of Prisons Health Services Inmate Local Hospital Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD SENSITIVE BUT UNCLASSIFIED — This information is confidential and must be appropriately safeguarded. Transfer To: Transfer Date: 08/10/2019 Health Problems Health Problem Status Hyperlipidemia, unspecified Current HYPERTRIGLYCERIDEMIA Sleep apnea Current Essential (primary) hypertension Current BY HX. Constipation, unspecified Current Low back pain Current Neuralgia and neuritis, unspecified Current No Diagnosis Current Prediabetes Current Injury, unspecified Current R/O self inflicted injuries. Body mass index (BMI) 27.0-27.9, adult Current Medications: All medications to be continued until evaluated by a physician unless otherwise indicated. Bolded drugs required for transport. Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take one capsule (100 MG) by mouth twice daily for 30 days Docusate Sodium 100 MG Cap Exp: 01/22/2020 SIG: Take one capsule (100 MG) twice daily by mouth with plenty of water Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML Exp: 10/28/2019 SIG: shake well take 10ml by mouth twice daily AS NEEDED Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by mouth with food OTCs: Listing of all known OTCs this Inmate is currently taking. None Pending Appointments Date Time Activity Provider 07/24/2019 00:00 Clinical Encounter Optometrist 01/07/2020 00:00 Chronic Care Visit Mid-Level Provider 07/01/2020 00:00 Chronic Care Visit Physician 01 07/09/2020 00:00 PPD Administration Nurse Pending Non-Medication Orders: Order Order Date Freauency Duration Details EKG 07/06/2019 One Time 66 y/o male Fecal Occult Blood 07/06/2019 One Time 3 different stools TB Clearance: Yes Last PPD Date: 07/09/2019 Induration: 0mm Last Chest X-Ray Date: TB Treatment: TB Follow-up Recommended: No Sickle Cell: Sickle Cell Trait/Disease: No Results: Sx free for 30 days: Yes Generated 08/10/2019 07:00 by SDNY_00017417 RN Bureau of Prisons - NYM Page 1 of 2 EFTA00139054 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD SENSITIVE BUT UNCLASSIFIED — This information is confidential and must be appropriately safeguarded. 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 Address 1: 150 PARK ROW Address 2: City/State/Zip: NEW YORK, New York 10007 Name/Title of Person Completing Form: Phone Number: 6468366300 RN Date: 08/10/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 DOB: 01/20/1953 Sex: M Generated 08/10/2019 07:00 by SDNY_00017418 RN Bureau of Prisons - NYM Page 2 of 2 EFTA00139055 Bureau of Prisons Health Services Vitals All Begin Date: 07/06/2019 Reg #: 76318-054 End Date: 05/11/2020 Inmate Name: EPSTEIN, JEFFREY EDWARD Temperature: Date Time Fahrenheit Celsius Location 07/24/2019 13:12 NYM 97.8 36.6 Oral Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 NYM 97.5 36.4 Oral Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM 97.3 36.3 Oral Orig Entered: 07/09/2019 12:51 EST Pulse: Date Time 07/30/2019 13:02 Bate Per Minute Location 94 Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:40 Orig Entered: 07/30/2019 09:30 Orig Entered: 07/28/2019 20:28 Orig Entered: 07/28/2019 06:57 Orig Entered: 07/24/2019 13:12 Orig Entered: 07/23/2019 06:30 Orig Entered: 07/09/2019 12:49 Orig Entered: 07/06/2019 21:43 Orig Entered: Respirations: Date Time 07/30/2019 09:30 Orig Entered: 07/28/2019 20:28 Orig Entered: 07/28/2019 06:57 Orig Entered: 07/23/2019 06:30 Orig Entered: 07/09/2019 12:49 07/30/2019 13:04 07/30/2019 12:59 07/28/2019 20:29 07/28/2019 06:58 07/24/2019 13:14 07/23/2019 08:33 07/09/2019 12:51 07/06/2019 21:48 MLP MLP MLP 88 Via Machine EST 87 Via Machine EST 81 EST 82 EST 83 EST 92 EST 82 EST 90 EST Provider . MLP . MLP . MLP EDO= Provider MD MD MD RN RN Via Machine Regular MLP Via Machine Regular MLP Via Machine Regular MLP Via Machine PA-C Rate Per Minute Provider NYM 12 07/30/2019 12:59 EST NYM 14 07/28/2019 20:29 EST NYM 07/28/2019 06:58 EST NYM 07/23/2019 08:33 EST NYM MD MD RN RN 14 RN TM,MLP MLP 16 . MLP RN MD MD MD RN RN MLP MLP MLP PA-C Generated 05/11/2020 09:57 by Allen, Tamara OGC Bureau of Prisons DAN SDNY 00017419 — Page 1 el 3 EFTA00139056 Begin Date: 07/06/2019 Reg #: 76318.054 End Date: 05/11/2020 Inmate Name: EPSTEIN, JEFFREY EDWARD Date Time Rate Per Minute Provider Orig Entered: 07/09/2019 12:51 EST . MLP 07/06/2019 21:43 NYM 15 PA-C Orig Entered: 07/06/2019 21:48 EST PA-C Blood Pressure: Date Time Value 07/30/2019 13:02 NYM 114/84 Location Left Arm Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:40 NYM 125/60 Right Arm Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:30 NYM 108/86 Left Arm Orig Entered: 07/30/2019 12:59 EST 07/28/2019 20:28 NYM 157/91 Orig Entered: 07/28/2019 20:29 EST 07/28/2019 06:57 NYM 138/80 Orig Entered: 07/28/2019 06:58 EST 07/24/2019 13:12 NYM 132/89 Right Arm Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 NYM 140/85 Right Arm Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM 117/66 Right Arm Orig Entered: 07/09/2019 12:51 EST 07/06/2019 21:45 NYM 164/90 Right Arm Orig Entered: 07/06/2019 21:48 EST 07/06/2019 21:43 NYM 155/83 Left Arm Orig Entered: 07/06/2019 21:48 EST Blood Glucose: Date 08/04/2019 Orig 08/02/2019 Orig 08/01/2019 Orig 07/31/2019 Orig Position Standing Standing Sitting Sitting MLP Sitting MLP Sitting MLP Sitting PA-C Sitting PA-C Time Value (mg/d11 Ivo 08:30 156 Non-Fasting Entered: 08/04/2019 09:08 EST 06:30 97 Non-Fasting Entered: 08/02/2019 08:16 EST 06:30 103 Non-Fasting Entered: 08/01/2019 09:00 EST 06:15 108 Non-Fasting Entered: 07/31/2019 08:36 EST SaO2: Date lime Value(%) Air 07/30/2019 09:30 NYM 98 Room Air Orig Entered: 07/30/2019 12:59 EST 07/28/2019 20:28 NYM 98 Orig Entered: 07/28/2019 20:29 EST 07/28/2019 06:57 NYM 98 Generated 05/11/2020 09:57 by Allen. Tamara OGC MLP MLP MLP Cuff Size provider MD MD MD RN RN Adult-regular Adult-regular Adult-regular Adult-regular Adult-regular MD MD MD RN RN MLP MLP MLP PA-C PA-C Regular Insulin Provider RN Provider MD RN Bureau of Prisons DAN MD RN RN RN . MLP . MLP . MLP SDNY 00017420 - Page 2 of 3 EFTA00139057 Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date Time Value(%) Air Provider Orig Entered: 07/28/2019 06:58 EST RN 07/24/2019 13:12 NYM 96 Room Air . MLP Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 NYM 96 Room Air Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM 97 Room Air Orig Entered: 07/09/2019 12:51 EST 07/06/2019 21:43 NYM 95 Room Air Orig Entered: 07/06/2019 21:48 EST MLP MLP MLP PA-C Height: Date Time Jnches Cm Provider 07/09/2019 12:49 NYM 70.0 177.8 MLP Orig Entered: 07/09/2019 12:51 EST MLP 07/06/2019 21:43 NYM 72.0 182.9 PA-C Orig Entered: 07/06/2019 21:48 EST PA-C Weight: Date Time J,kg Kg. Waist Circum Provider 07/30/2019 09:30 NYM 194.2 88.1 MLP MLP PA-C Orig Entered: 07/30/2019 12:59 EST MD 07/09/2019 12:49 NYM 194.4 88.2 . MLP Orig Entered: 07/09/2019 12:51 EST 07/06/2019 21:43 NYM 200.0 90.7 Orig Entered: 07/06/2019 21:48 EST MLP PA-C PA-C MD Generated 05/11/2020 09:57 by Allen, Tamara OGC Bureau of Prisons - DAN SDNY 00017421 - Page 3 of 3 EFTA00139058 Bureau of Prisons Health Services PPDs Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Admin: Location 07/06/2019 21:39 Right Forearm Orig Entered: 07/06/2019 21:43 EST Total: 1 Provider PA-C PA-C Reading, Induration : Provider 07/09/2019 12:47 0 mm MLP Orig Entered: 07:09'2019 12:47 EST MLP Generated 05,11,2020 09:57 by Allen. Tamara OGC SONY 00017422 Bureau ol Prisons - DAN Page 1 ol EFTA00139059 76318-054 EPSTEIN. JEFFREY Medication Orders Medication Administration Record JULY 2019 Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Ord. Date 07.3019 1421 Exp. Date 07,3109 10.01 Inject regular insulin subcutaneously per sliding scale: twice daily —pill line"' for 7 days NYM 122148- NYM Insulin Reg (10 ML) 100 UNITSML MD PAN Ord. Date 07.31119 1000 Exp. Date 0807019 09:59 MD Inject regular insulin subcutaneously per sliding scale: each morning for 7 days "'pill line"' NYM 122160 NYM Insulin Reg (10 ML) 100 UNITSML In! PAN Providers: YJ Documentation Codes: ORD - Order I NI -- Dose Not Indicated Registration 4. 76318-054 Pt. Name: EPSTEIN. JEFFREY DOB: 01.20:53 Report information is current as of the date and time of printing: 05. 11.2020 (43151,Em 0,7423 EFTA00139060 76318.054 EPSTEIN. JEFFREY Medication Orders 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 Ord. Date 0'731/9 10 00 Exp. Dale 0807/19 09:59 MD Inject regular insulin subcutaneously per sliding scale: each morning for 7 days "'pill line— NYM 122160- NYM Insulin Reg (10 ML) 100 UNITSML Iry VAN Providers: YJ Documentation Codes: ORD = Order I NI -- Dose Not Indicated Registration #. 76318-054 Pt. Name: EPSTEIN. JEFFREY DOB: 01.20:53 Report information is current as of the date and time of printing: 0511.2020 L._ (NT, E m0,7424 EFTA00139061 Bureau of Prisons Health Services Devices and Equipment Start Date: 07/06/2019 Stop Date: 05/11/2020 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Device/Equipment Start Date Stop Date Date Returned Obtained From Comments C-Pap 07/30/2019 14:05 EST MD 07/30/2019 Personal PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Total: 1 Generated 05/11/2020 09:57 by Allen, Tamara OGC Bureau of Prisons - DAN SDNY_0001744099 1 of 1 EFTA00139062 Bureau of Prisons Health Services Pain Management Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Date Intervention 07/12/2019 13:25 MEDROL DOSE PACK Orig Entered: 07/12/2019 13:28 EST MD Pain Quality Location Pie Post Provider Shooting Back-Middle 5 MD Generated 05/11/2020 09:57 by Allen, Tamara OGC Bureau of Prisons • DAN SDNY 00017426 - Page 1 of 1 EFTA00139063 Bureau of Prisons Health Services Modified Diet Request Types of Diets: Clear Liquid Exp Date: Low Fat Exp Date: Mechanical Soft Exp Date: Low Cholesterol Exp Date: Low Triglyceride Exp Date: Renal Exp Date: _ Full Liquid Exp Date: Sodium Controlled Exp Date: _ Snack Exp Date: Diabetic Exp Date: Calorie Controlled Exp Date: X Other: FISH ALLERGIES. Exp Date: 07/30/2020 Comments: MD Health Service Staff EPSTEIN, JEFFREY EDWARD Inmate Name 76318-054 07/30/2019 Reg# Date Generated 07/30/2019 14:57 by SDNY_00017427 MD Bureau of Prisons - NYM Page 1 of 1 EFTA00139064 Bureau of Prisons Health Services Allergies Reg li: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Mem No Known Allergies Orig Entered: Total: 1 07/06/2019 21:40 EST Date Noted Reaction 07/06/2019 PA-C Generated 05/11/2020 09:57 by Allen. Tamara OGC Bureau of Prisons - DAN SDNY_00017428 Page 1 of 1 EFTA00139065 Bureau of Prisons Health Services Patient Education Assessments & Topics Reg 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Assessments Assessment Learns Best By Primary Language Years of Education Barriers To Education 07/09/2019 Speaking/Listening English 12 None Orig Entered: 07/09/2019 12:52 EST Total: 1 Topics Date initiated Format flandouVTopic 07/30/2019 Counseling Access to Care Orig 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 Orig 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 Orig Entered: 07/24/2019 13:23 EST 07/23/2019 Counseling Access to Care Orig Entered: 07/23/2019 09:04 EST 07/23/2019 Counseling Plan of Care 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 Outcome Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Verbalizes Understanding Provider Provider Generated 05/11/2020 09:57 by Allen. Tamara OGC Bureau of Prisons • DAN S0NY_00017429 Page 1 of 2 EFTA00139066 Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Topics Date Initiated Format flandouUTopic Orig Entered: 07;12/2019 13:33 EST Total: 10 Outcome Provider Generated 05,1112020 09:57 by Allen, Tamara OGC SDNY00017430 Bureau of Prisons - DAN Page 2 of 2 EFTA00139067 Bureau of Prisons Health Services Blood Glucose Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD (Reference Range: Random or Fasting 70 - 100, 2 hour post-prandial 70 - 140) Date lime Value Type 08/04/2019 08:30 NYM 156 Non-Fasting Orig Entered: 08/04/2019 09:08 EST RN 08/02/2019 06:30 NYM 97 Non-Fasting Orig Entered: 08/02/2019 08:16 EST MLP 08/01/2019 06:30 NYM 103 Non-Fasting Orig Entered: 08/01/2019 09:00 EST MLP 07/31/2019 06:15 NYM 108 Non-Fasting Orig Entered: 07/31/2019 08:36 EST MLP Total: 4 Comments Generated 05/11/2020 09:57 by Allen, Tamara OGC Bureau of Prisons • DAN S0NY_00017431 Page 1 of 1 EFTA00139068 Bureau of Prisons Health Services Health Problems Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Description Ana Code Type Code Diag. Date Status Status Date Current Hyperlipidemia, unspecified 07/12/2019 13:48 EST MD ICD-10 E785 07/12/2019 Current HYPERTRIGLYCERIDEMIA Sleep apnea 07/12/2019 13:56 EST MD ICD-10 G4730 07/12/2019 Current Essential (primary) hypertension 07/30/2019 13:13 EST MD ICD-10 110 07/30/2019 Current BY HX. Constipation, unspecified 07/09/2019 12:58 EST MLP ICD-10 K5900 07/09/2019 Current Low back pain 07/12/2019 13:30 EST MD ICD-10 M545 07/12/2019 Current Neuralgia and neuritis, unspecified 07/12/2019 13:30 EST MD ICD-10 M792 07/12/2019 Current No Diagnosis 07/09/2019 10:28 EST PhD/Chief I DSM-IV No Dx 07/09/2019 Current Psychologist Prediabetes 07/30/2019 13:26 EST MD ICD-10 R7303 07/30/2019 Current Injury, unspecified 07/23/2019 09:04 EST MLP 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 MD ICD-10 Z6827 07/30/2019 Current Total: 10 Generated 05/11/2020 09:57 by Allen, Tamara OGC Bureau of Prisons • DAN S0NY_00017432 Page 1 of 1 EFTA00139069 Bureau of Prisons Health Services Vision Screens Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Vision Screen on 07/09/2019 12:52 Blindness: Distance Vision: OD: 20/100 OS: 20/70 OU: Near Vision: OD: OS: OU: With Corrective Distance Vision: OD: OS: OU: Near Vision: OD: OS: OU: Present Glasses - Distance Refraction - Distance Sphere Cylinder Axis Add Sphere Cylinder Axis Add R: R: L: L: Color Test: Tonometry: R: L: Comments: Needs evaluation with optometrist. Orig Entered: 07/09/2019 12:54 EST . MLP Generated 05/11/2020 09:57 by Allen, Tamara OGC SDNY 00017433 Bureau of Prisons - DAN — Page 1 of 1 EFTA00139070 Bureau of Prisons Health Services Immunizations Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Immunization Jmmunization Date Administered Location Dosage Drug Mfg latit gxp Date Hepatitis A and B (TwinRx) History Unknown Orig Entered: 07/09/2019 12:51 EST MLP Measles/Mumps/Rubella Series History Unknown Orig Entered: 07/09/2019 12:51 EST MLP Smallpox Series History Unknown Orig Entered: 07/09/2019 12:51 EST Tetanus -. MLP History Unknown Orig Entered: 07/09/2019 12:51 EST MLP Varicella Series History Unknown Orig Entered: 07/09/2019 12:51 EST Total: 5 MLP Generated 05/11/2020 09:57 by Allen, Tamara OGC Bureau of Prisons • DAN S0NY_00017434 Page 1 of EFTA00139071 Bunau of Prisons Hear! Services Medical Duty Status Reg #: 76318-054 in. late Name: EPSTEIN. JEFFREY EDWARD Housing Status confined to the living quarters except _meals pill line _ _treatments Exp. Date: _ on complete bed rest: _bathroom privileges only Exp. Date: X cell: cell on first floor single cell X lower bunk airborne infection isolation Exp. Date: 10:09/2019 other: Exp. Date: Physical limitation/Restriction all sports Exp. Date: weightlifting: _upper body _lower body Exp. Date: cardiovascular exercise: _running _jogging _walking _softball Exp. Date: _football _basketball _handball _stationary equipment other: Exp. Date: May have the following equipment in his / her possession: Equipment Start Date C-Pap 07/30,2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Work Restriction / Limitation: Cleared for Food Service: Yes X No Restrictions Comments: N/A Beaudouin, Robert MD Health Services Staff Date End Date Return Date 07/30/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Quarters: null ALL EXPIRATION DATES A RE AT 24:00 Generated 05/11/2020 09:57 by Allen. Tamara OGC DA .) - DAN SDNY 00017435 Page 1 oft EFTA00139072 Bunau of Prisons Hear! Services Medical Duty Status Reg #: 76318-054 in. late Name: EPSTEIN. JEFFREY EDWARD Housing Status confined to the living quarters except _meals pill line _ _treatments Exp. Date: _ on complete bed rest: _bathroom privileges only Exp. Date: X cell: cell on first floor single cell X lower bunk airborne infection isolation Exp. Date: 10:09/2019 other: Exp. Date: Physical limitation/Restriction all sports Exp. Date: weightlifting: _upper body _lower body Exp. Date: cardiovascular exercise: _running _jogging _walking _softball Exp. Date: _football basketball handball stationary equipment other: May have the following equipment in his / her possessio Work Restriction / Limitation: Cleared for Food Service: Yes X No Restrictions Comments: N/A MLP Exp. Date: 07/09/2019 Health Services Staff Date Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Quarters: null ALL EXPIRATION DATES ARE AT al:00 ,t‘ V 4I Y ir i9 t e a l .< se b t • t Got C 4 1Ok e 0 euret - DAN Generated 05/11/2020 09:57 by Allen. Tamara OGC SONY 00017436 Page 1 (21 EFTA00139073 Bureau of Prisons Health Services Medication Summary Historical Complex: NYM--NEW YORK MCC Inmate: EPSTEIN, JEFFREY EDWARD Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318-054 Quarter: ???-???? Medications listed reflect prescribed medications from the begin date to end date on this report. Allergies: Denied Active Prescriptions Bisacodyl E.C. 5 MG TAB Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10 days Rx#: 121757-NYM Doctor: MLP Start: 07/09/19 Exp: 07/19/19 D/C: 07/12/19 Pharmacy Dispensings: 10 TAB in 307 days Docusate Sodium 100 MG Cap Take one capsule (100 MG) by mouth twice daily for 30 days Rx#: 121823-NYM Doctor: MD Start: 07/12/19 Exp: 08/11/19 D/C: 08/10/19 Pharmacy Dispensings: 60 CAP in 304 days Docusate Sodium 100 MG Cap Take one capsule (100 MG) twice daily by mouth with plenty of water Rx#: 122084-NYM Doctor: MD Start: 07/26/19 Exp: 01/22/20 D/C: 08/10/19 Pharmacy Dlspensings: 30 CAP in 290 days Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML shake well take 2 tablespoonful twice daily by mouth Rx#: 121835-NYM Doctor: MD Start: 07/12/19 Exp: 07/14/19 Pharmacy Dispensings: 473 ML in 304 days Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML shake well take 10ml by mouth twice daily AS NEEDED Rx#: 122150-NYM Doctor: MD Start: 07/30/19 Exp: 10/28/19 D/C: 08/10/19 Pharmacy Dispensings: 473 ML in 286 days methylPREDNISolone 4 MG Tab [ 21 count Pack) Take the tablet by mouth as directed Rx#: 121836-NYM Doctor: MD Start: 07/12/19 Exp: 07/18/19 Pharmacy Dispensings: 21 tab in 304 days methylPREDNISolone 4 MG Tab [ 21 count Pack) Take the tablet by mouth as directed Rx#: 122149-NYM Doctor: MD Start: 07/30/19 Exp: 08/05/19 Pharmacy Dispensings: 21 tab in 286 days Generated 05/11/2020 09:57 by Allen, Tamara OGC SDNV 00017437 Bureau of Prisons _ sons - DAN Page 1 of 2 EFTA00139074 Complex: NYM--NEW YORK MCC Inmate: EPSTEIN, JEFFREY EDWARD Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318-054 Quarter: ???-???? Active Prescriptions Omega 3 (Vascepa) 1 GM Capsule Take two capsules (2 GM) twice daily by mouth with food Rx#: 121885-NYM Doctor: MD Start: 07/17/19 Exp: 01/13/20 D/C: 08/10/19 Pharmacy Dispensings: 180 Cap in 299 days Insulin Reg (10 ML) 100 UNITS/ML Inj Inject regular insulin subcutaneously per sliding scale: twice daily "'pill line— for 7 days "'pill line— Rx#: 122148-NYM Doctor: MD Start: 07/30/19 Exp: 08/06/19 D/C: 07/31/19 Pharmacy Dispensings: 0 ML in 286 days Insulin Reg (10 ML) 100 UNITS/ML Inj Inject regular insulin subcutaneously per sliding scale: each morning for 7 days "'pill line"' "'pill line"' Rx#: 122160-NYM Doctor: Start: 07/31/19 Exp: 08/07/19 MD Pharmacy Dispensings: 0 ML in 285 days Generated 05/11/2020 09:57 by Allen, Tamara OGC SDNY_00017438 Bureau of Prisons • DAN Page 2 of 2 EFTA00139075 Bureau of Prisons Health Services Dental Health History Screen Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/26/2019 07:54 Provider: DDS Unit: H01 ASSESSMENTS: Health Problems as of Dental Health History Encounter date: 07/26/2019 07:54 Health Problems Health Problem Status Hyperlipidemia, unspecified Current HYPERTRIGLYCERIDEMIA Sleep apnea Current Constipation, unspecified Current Low back pain Current Neuralgia and neuritis. unspecified Current No Diagnosis Current Injury, unspecified Current R/O self inflicted injuries. Medical History as of Dental Health History Encounter date: 07/26/2019 07:54 Medical History: Allergies: Denied Seizures: Denied Diabetes: Denied Cardiovascular: Denied CVA: Denied Hypertension: Denied Respiratory: Denied Sickle Cell Anemia: Denied Carcinoma/Lymphoma: Denied HIV History: When Tested: 2019 Test Result: Negative When Diagnosed AIDS: Last CD4: Comments: Hepatitis: Denied SDNY_K09137,713.3? 3 Generated 07;26,2019 07:59 by DDS Bureau of Prisons - NYM EFTA00139076 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/26/2019 07:54 Provider: DDS Unit: H01 Other Infectious Diseases: Syphilis: No Syphilis Last Treatment: N/A Genital Warts: No Chlamydia: Yes Gonorrhea: No Herpes: No Chicken Pox: Yes Other: No Comments: Chlamydia in 2015, treated Chicken pox in childhood Other Health Issues: Other Medical Conditions And Treatment: sleep apnea Current Medical Conditions: Other Current Treatments: Pregnant: N/A Dental Observations as of Dental Health History Encounter date: 07/26/2019 07:54 History: Alcohol: No Methamphetamine: No Tobacco products: No Other drugs: No Sensitive teeth: No Bleeding gums: Yes Food impaction: Yes Pain around 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 07/26:2019 07:59 by ODS Bureau of Prisons - NYM SDNY40a0glett o? 3 EFTA00139077 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/26/2019 07:54 Provider: DDS Unit: H01 Cardiac Condition Requiring Prophylaxis: No Prosthetic joint(s): No Radiation history of head or neck: No Excessive bleeding: No Bisphosphonates: No Comments: Medications as of Dental Health History Encounter date: 07/26/2019 07:54 Medications: Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take one capsule (100 MG) by mouth twice daily for 30 days Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by mouth with food OTCs: Listing of all known OTCs this inmate is currently taking. Instructed inmate how to obtain medical, dental, and mental health care. Copay Required:No Cosign Required: No Telephone/Verbal Order: No Completed by DDS on 07/26/2019 07:59 SDNY_R0gle7314.31 3 Generated 07/26/2019 07:59 by DDS Bureau of Prisons - NYM EFTA00139078 Bureau of Prisons Health Services Dental A&O Exam Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/26/2019 07:47 Provider: Reg #: 76318-054 Facility: NYM DDS Unit: H01 Reviewed Health Status: Yes Occlusion: Class I Oral Hygiene: Fair CPITN: 3 2 3 3 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 given: Yes Dental A&O Screening Exam findings entered on EPSTEIN, JEFFREY EDWARD by DDS on 07/26/2019 07:47. SDNY_ROg1e714401 Generated 07/26/2019 08:00 by DDS Bureau of Prisons - NYM EFTA00139079 Bureau of Prisons Health Services Dental Soap/Admin Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/18/2019 13:48 Provider: DeBruce, Juanita Dental Asst Unit: Z05 Screening encounter at Dental Clinic. Reason Not Done: Unavailable Comments: Patient has had several call outs for his Dental A & O screening but has not been escorted to the dental clinic. Cosign Required: No Completed by DeBruce, Juanita Dental Asst on 07/19/2019 13:49. Generated 07/19/2019 13:49 by DeBruce. Juanita Dental SDNY_00017443 Bureau of Prisons • NYM Page 1 of 1 EFTA00139080 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 08/08/2019 10:02 Provider: PhD/Chief Reg #: 76318-054 Unit Team: 5 Focus of Session Inmate Epstein was seen today for a follow-up session in SHU. Subjective/Objective Presentation Inmate Epstein stated he is feeling okay and has been eating his meals. He reported his sleep as "fair" and would like to go the general population. He denied any mental health symptoms at this time and denied any feelings of depression and/or anxiety. Inmate Epstein denied any suicidal ideation, intention, or plan. He currently has a cellmate and appears to interact with him. Inmate Epstein continues to spend his days and evening with his attorney's in the attorney conference room. He told this writer he received his PAC number to make phone calls. Inmate Epstein indicated he has only had a couple of phone calls over the speaker phone and wondered "if that counted" as his monthly phone contact. He also reported he his missing some books he was reading in the suicide watch area prior to returning to the SHU. Other than complaints about the prison and concerns regarding his housing, he had no mental health concerns today. He did not appear to be in any distress and the SHU Staff have not reported any unusual behaviors on his part. fntervention(s) Inmate EPSTEIN was provided with brief supportive interventions and psychoeducation regarding additional coping strategies. Inmate EPSTEIN was receptive to these interventions. Progress/Plan Inmate EPSTEIN was educated about both routine and emergency procedures for contacting Psychology staff. He was reminded of the self-help books and audiotapes available through the Psychology department. There appears to be no need for follow up at this time. He will be seen in weekly rounds and monthly for SHU reviews. Completed by PhD/Chief Psychologist on 08/08/2019 10:09 Generated 08/08/2019 10:09 by PhD/Chiel Bureau of Prisons - NYM SDNY 00017444 Page 1 of 1 EFTA00139081 Bureau of Prisons Psychology Services Suicide Risk Assessment "SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facilit : NYM Date: 08/01/2019 13:29 Provider: PsyD Reg #: 76318-054 Unit Team: 5 Type of Housing: SHU- Administrative Segregation Cell Accommodation: Double-Cell FINDINGS This assessment and the resulting recommendations are based on the following sources of information: Clinical Interview, Medical Record, Psychology Data System, Sentry Reason for Referral R & D staff reported to this writer this morning at about 8:30 AM on 8/01/19 that yesterday when Mr. Epstein was brought back from court the US Marshals asked him to sign a form that noted Mr. Epstein has "suicidal tendencies." Mr. Epstein was seen for a Suicide Risk Assessment at about 1:00 PM on 8/01/19 in Attorney Conference. This note is being entered at about 4:20 PM on 8/01/19. Mental Health History According to a Suicide Risk Assessment dated 7/09/19 by Dr. "Inmate Epstein denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time." Self-Harm History According to a Suicide Risk Assessment dated 7/09/19 by Dr. "Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in the past." According to this writer's Suicide Risk Assessment dated 7/23/19, "It is unclear at this time if he had placed the string around his neck or if someone else did." Current Problem R & D staff reported to this writer this morning at about 8:30 AM on 8/01/19 that yesterday when Mr. Epstein was brought back from court the US Marshals asked him to sign a form that noted Mr. Epstein has "suicidal tendencies." This is likely due to the incident on 7/23/19, but as a precaution another Suicide Risk Assessment was conducted. Mr. Epstein seemed surprised that there was a form noting suicidal tendencies. He denied stating he was suicidal. He said he saw the DHO today and he said his incident report for the marks on his neck was expunged. He stated even though he has his cpap machine now, he said his cellmate talks at night and he stated this keeps him up. This writer offered to talk to the SHU Lt. to have him housed with a different cellmate, but he stated he wants to give it 3 to 4 days to see if he wants a different cellmate. He complained about the noise in SHU. Current Mental Status 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 Current Mental Status: He exhibited a neutral mood with a mildly restricted range of affect. His speech was logical and SDNY_00017445 Generated 08/01/2019 16:21 by PsyD Bureau of Prisons - NYM Page 1 of 3 EFTA00139082 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M F ili : NYM Date: 08/01/2019 13:29 Provider: PsyD Reg #: 76318-054 Unit Team: 5 coherent, with no loosening of associations or tangential, circumstantial or irrelevant speech. Auditory and visual hallucinations were denied, and delusions were not elicited. He did not engage in any bizarre or inappropriate behavior. He denied current suicidal or self harm ideation and he agreed to immediately tell staff if he starts to have suicidal or self harm thoughts. He was future oriented. He does not appear to be an immediate danger to self. He denied thoughts of hurting others and he agreed to tell staff if he has these thoughts. RISK AND PROTECTIVE FACTORS ASSESSED: This writer screened the inmate for a variety of empirically validated factors commonly associated with risk for self-harm and suicide. The following STATIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related behaviors: High Profile Crime, Lack of family connections. Sex offender status The following DYNAMIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related behaviors: Current physical pain, Sleep problems The following PROTECTIVE factors were assessed to be present and may decrease the inmate's risk of suicide:Able to identify reasons to live, Denial of suicidal ideation/intention/plans, Future orientation, Religious beliefs against suicide, Supportive family relationships, View of death as negative, Willingness to engage in treatment Risk Factors: He was found by staff in his cell in SHU on 7/23/19 with a string loosely tied around his neck, which Mr. Epstein stated he did not remember anything about. It is still unclear at this time if Mr. Epstein had placed the string around his own neck or if someone else did. He has a high profile sex offense case. He stated his lower back hurts and he stated Medical is aware of this. He stated he has difficulty sleeping even with his cpap machine because he stated his cellmate talks at night. Protective Factors: He denied current suicidal or self harm thoughts and agreed to tell staff if he starts to have these thoughts. He had denied a history of self harm and suicide attempts. He had denied a family history of suicidal and self harm attempts. He had denied having any chronic medical conditions. He denied feeling hopeless. He had denied a history of childhood abuse. He denied fearing for his safety at this time. He denied feeling like a burden to anyone. He stated he lives for and plans to finish this case and to go back to his normal life. He said his friends and Lawyers are emotionally supportive. He said he is Jewish and he said in his religion suicide is against the religion. Overall, his current protective factors override his risk factors for suicidality. He is currently psychologically stable. He denied feeling hopeless. He is reporting positive future plans and reasons to live for. He said he has social supports in the community and his Lawyers visit him often. He denied any current suicidal or self harm ideation, intention or plan. Suicide Watch is not indicated at this time. DIAGNOSIS- No Diagnosis, No Dx - Current CONCLUSIONS The Overall Acute Suicide Risk for this Inmate is: Low Overall Chronic Suicide Risk for this Inmate is: Absent RECOMMENDATIONS 1. Suicide Watch is not indicated at this time. 2. Supportive and educative interventions were provided. 3. He was educated about both routine and emergency procedures for contacting Psychology staff. 4. He will be seen in follow up by Psychology next week to monitor his mental status and to provide further intervention if needed. 5. In the meantime, he was encouraged to self-refer to Psychology if needed to which he agreed and seems capable of doing. 6. If he remains in SHU, he will be seen by Psychology in SHU Rounds and in SHU Reviews. Suicide Watch: A suicide watch is not warranted at this time Generated 08/01/2019 16:21 by PsyD Bureau of Prisons - NYM SDNY 00017446 — Page 2 of 3 EFTA00139083 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facilit : NYM Date: 08/01/2019 13:29 Provider: PsyD Reg #: 76318-054 Unit Team: 5 Completed by PsyD on 08/01/2019 16:21 Generated 08/01/2019 16:21 by PsyD Bureau of Prisons - NYM SDNY 00017447 — Page 3 of 3 EFTA00139084 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/31/2019 10:35 Provider: PsyD/DAPC Reg #: 76318-054 Unit Team: 5 Focus of Session Mr. EPSTEIN was seen today by this writer for a follow up appointment after he was removed from Psychological Observation yesterday. Subjective/Objective Presentation Mr. EPSTEIN presented in a pleasant mood and reported he is generally doing well. He stated, "I could be better," but acknowledged he is doing as well as can be expected given his circumstances. He reported he is going to court today for a status hearing. He stated he generally slept well last night and is readjusting to being placed back in SHU. He reported getting along well with his cell mate. He was informed of appropriate procedures for contacting Psychology staff while he is in SHU, if needed. Current Mental Status: Mr. EPSTEIN was alert and oriented. He was polite, calm, and cooperative in demeanor. He exhibited a neutral affect with appropriate range. Eye contact and hygiene were appropriate. He spoke with normal rate, tone, and volume. His thoughts were organized and coherent, with no loosening of associations or tangential, circumstantial, or irrelevant content. There was no evidence of perceptual disturbance, delusional ideation, or a formal thought disorder. He did not engage in any bizarre or inappropriate behavior. He noted having normal sleeping and eating habits. Mr. EPSTEIN explicitly denied recent and current suicidal ideation, planning, and intent. He was future- oriented and expressed a commitment to life and safety, agreeing to contact staff immediately should he experience suicidal ideation or psychological distress. He also denied thoughts of harming others. Intervention(s) Supportive interventions and cognitive behavioral therapeutic techniques were utilized. Mr. EPSTEIN was receptive to all interventions. Progress/Plan Mr. EPSTEIN was educated about both routine and emergency procedures for contacting psychology. There appears to be no need for follow-up at this time and he expressed willingness to self refer to psychology staff if needed. He will continue to be seen during routine SHU rounds and SHU reviews while he is housed in SHU. He was encouraged to reach out for PRN services should he experience any psychological distress. Completed by PsyD/DAPC on 07/31/2019 10:56 Generated 07/31/2019 10:56 by PsyD/DAPC Bureau of Prisons - NYM SDNY_00017448 Page 1 of 1 EFTA00139085 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/30/2019 12:01 Provider: PsyD Reg #: 76318-054 Unit Team: 5 Focus of Session He was seen by writer while he was on Psych Observation. Subjective/Objective Presentation He stated he hasn't slept well at MCC-NY because he hasn't had his cpap machine. He stated it is here and he will be able to start using it tonight. He discussed how he does not think he will able to sleep in SHU and how he does not like SHU because of the noise. He discussed issues on not getting some medication with Medical today. The "Eating/Shower Chart" indicated yesterday he ate breakfast and dinner, drank liquids, and took a shower when offered and so far today it noted he ate breakfast and drank liquids. The Psych Observation Log noted he slept, drank water, went to legal, and talked to an Inmate Companion about investments. Current Mental Status: He exhibited a neutral mood with a full range of affect. His speech was logical and coherent, with no loosening of associations or tangential, circumstantial or irrelevant speech. Auditory and visual hallucinations were denied, and delusions were not elicited. He did not engage in any bizarre or inappropriate behavior. There was no indication of disturbed thought process or content. Intellectual ability appeared to be above average. Personal hygiene was adequate. He denied current suicidal or self harm ideation and he agreed to immediately tell staff if he starts to have suicidal or self harm thoughts. He was future oriented. He does not appear to be an immediate danger to self. He denied thoughts of hurting others and he agreed to tell staff if he has these thoughts. Intervention(s) Supportive and educative interventions were provided. When asked about the Turning Point handouts for coping in SHU, he stated he already knows these strategies before he read the handouts and had tried them when he was in SHU the last time. He stated with the noise in SHU, he said the strategies will not work. He was encouraged to try them. Progress/Plan The Chief Psychologist was consulted. Psych Observation will be discontinued. Mr. Epstein was educated about both routine and emergency procedures for contacting Psychology staff. He will be seen in follow up by Psychology tomorrow to monitor his mental status and to provide further intervention if needed and he was informed that he will be seen by Psychology tomorrow. In the meantime, he was encouraged to self-refer to Psychology if needed to which he agreed and seems capable of doing. If he remains in SHU, he will be seen by Psychology in SHU Rounds and in SHU Reviews. The SHU Lt. was informed that Mr. Epstein needs to be housed with an appropriate cellmate. Completed by PsyD on 07/30/2019 13:54 Generated 07/30/2019 13:54 by PsyD Bureau of Prisons - NYM SDNY 00017449 rage 1 of 1 EFTA00139086 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Institution Disciplinary Process Report Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/30/2019 12:01 Provider: PsyD Reg #: 76318-054 Unit Team: 5 Reason for Referral and Identifying Information Inmate Epstein was referred by Unit Manager Proto for an evaluation of competency to proceed with the disciplinary process for actions resulting in an incident report. On 7/23/19, inmate Epstein was charged with code 228 (Tattooing or Self-Mutilation). These infractions were assigned incident report number 3282555. Background Information According to a Suicide Risk Assessment dated 7/09/19 by Dr. "Inmate Epstein denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time." According to a Suicide Risk Assessment dated 7/09/19 by Dr. "Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in the past." According to this writers Suicide Risk Assessment dated 7/23/19, "It is unclear at this time if he had placed the string around his neck or if someone else did." Clinical Interview and Mental Status Exam Inmate Epstein still does not remember how he obtained the marks around his neck. Current Mental Status: He exhibited a neutral mood with a full range of affect. His speech was logical and coherent, with no loosening of associations or tangential, circumstantial or irrelevant speech. Auditory and visual hallucinations were denied, and delusions were not elicited. He did not engage in any bizarre or inappropriate behavior. There was no indication of disturbed thought process or content. Intellectual ability appeared to be above average. Personal hygiene was adequate. He denied current suicidal or self harm ideation and he agreed to immediately tell staff if he starts to have suicidal or self harm thoughts. He was future oriented. He does not appear to be an immediate danger to self. He denied thoughts of hurting others and he agreed to tell staff if he has these thoughts. Clinical Impression According to his last Diagnostic and Care Level Formulation Note dated 7/09/19 by Dr. , "No Diagnosis, No Dx - Current." Findings The determination of whether an inmate is competent to proceed with the disciplinary process is based on a clinical assessment of the inmate's (1) ability to understand the nature of the proceedings, and (2) their ability to assist in their own defense. Depending on the outcome of the assessment, one of three findings can be made: (1) the inmate is COMPETENT to proceed with the disciplinary process; (2) the inmate is NOT PRESENTLY COMPETENT but could be restored to competence with treatment; or (3) the inmate is NOT COMPETENT and is unlikely to become competent. Recommendations Regarding Sanctions In the case of inmate Epstein, after a review of available psychological and psychiatric records as well as information pertaining to the offense conduct, it is determined that this inmate is: (X) COMPETENT to proceed with the disciplinary process. ( ) NOT PRESENTLY COMPETENT, but could become competent with treatment; it is recommended that the inmate for an updated competency assessment in 30 days. ( ) NOT COMPETENT and not likely to become competent. Generated 07/30/2019 12:33 by PsyD Bureau of Prisons - NYM SDNY_00017P450 age 1 of 2 EFTA00139087 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M F cility: NYM Date: 07/30/2019 12:01 Provider: PsyD Reg #: 76318-054 Unit Team: 5 Completed by PsyD on 07/30/2019 12:33 SDNY_00017palge 2 of 2 Generated 07130%2019 12:33 by PsyD Bureau of Prisons - NYM EFTA00139088 Bureau of Prisons Psychology Services General Administrative Note "SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/30/2019 12:01 Provider: PsyD Reg #: 76318-054 Unit Team: 5 Comments Psych Observation Discontinuation Note: Please see "Clinical Contact" dated today. Completed by PsyD on 07/30/2019 12:33 Generated 07/30/2019 12:33 by PsyD Bureau of Prisons - NYM SDNY_00017452 Page 1 of 1 EFTA00139089 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/29/2019 10:01 Provider: PhD/Chief Reg #: 76318-054 Unit Team: 5 Focus of Session Inmate Epstein was seen while on psychological observation today in the hospital area. Subjective/Objective Presentation Same presentation today, but he said he thinks his memory for the incident (injury to his neck) may be impaired because of his sleep apnea. He is supposed to get his CPAP machine today. He is aware he will be returning to SHU, but said he is feeling unwell due to his inability to sleep and numbness in his arm. He requested to have one good night of sleep with his CPAP and will return to SHU with a cellmate tomorrow. He then asked if he could remain down here where it is "safe" for the entire week. I told him he can stay down one more night to receive his CPAP and a good nights sleep, but that he would be returned to SHU tomorrow. It was explained that there is no mental health issues precluding him from returning to SHU tomorrow and that we could not house him in the SW/Hospital area because he felt safe or more comfortable for him. It was explained to him that he would be placed in a safe situation in the SHU. According to his log book and eating/shower chart, he has been eating and drinking when not in his legal visits. He has also been writing and attending his legal visits. Thtervention(s) Inmate EPSTEIN was provided with brief supportive interventions and psychoeducation regarding additional coping strategies. Inmate EPSTEIN was somewhat receptive to these interventions, but appears more concerned about getting his various needs in the prison (phone calls, recreation, housing placement concerns, etc.) Progress/Plan He will remain on psychological observation today and will transition to the SHU tomorrow. He will be seen by psychology daily to assess his mental status and psychological functioning. Completed by PhD/Chief Psychologist on 07/29/2019 10:26 Generated 07129/2019 10:26 by PhD/Chiel Bureau of Prisons - NYM SDNY 53 000174 Page 1 0l 1 EFTA00139090 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/28/2019 08:33 Provider: PsyD Reg #: 76318-054 Unit Team: 5 Focus of Session He was seen by writer while he was on Psych Observation. Subjective/Objective Presentation The "Eating/Shower Chart' noted that yesterday he ate breakfast. He is not in the Psych Observation cell for about 12 hours per day because of being in Attorney Conference with his Attorneys, so the "Eating/Shower Chart" may not reflect all of his meals. He stated he was served one meal in Attorney Conference yesterday. He stated he drinks a lot water at night. The Psych Observation log noted he talked about life in general population and he slept. Earlier he had complained that his right arm was numb and hanging. Nurse Columbo from Medical had seen him for this. When this writer was interviewing him, he said his right arm still feels somewhat numb and he said he cannot make a fist with that hand. He also said he has numbness on his neck. This writer notified Nurse Columbo. He stated last night when he flushed the toilet it kept flushing for 45 minutes. He stated he found it so aversive and upsetting that he said he sat in the corner and held his ears. He said because of this he was agitated for hours and was not able to sleep. The Lt. will be moving him to a different cell and he was informed of this. He stated the feeling he got with the noise of the toilet was similar to when he was in SHU. He said he may have something on the Autism spectrum. He said in the movie "Rain Man," the person with Autism had an aversion to noise. He stated he is also really good with numbers. Current Mental Status: He exhibited a mildly anxious mood with a full range of affect. His speech was logical and coherent, with no loosening of associations or tangential, circumstantial or irrelevant speech. Auditory and visual hallucinations were denied, and delusions were not elicited. He did not engage in any bizarre or inappropriate behavior. He denied current suicidal or self harm ideation and he agreed to immediately tell staff and Inmate Companions if he starts to have suicidal or self harm thoughts. He was future oriented. He does not appear to be an immediate danger to self. He denied thoughts of hurting others and he agreed to tell staff and Inmate Companions if he has these thoughts. Intervention(s) Supportive and educative interventions were again provided. He had not been given the Turning Point handouts yesterday that were on his cell door, so they were handed to him by staff today. Progress/Plan He will remain on Psych Observation in an abundance of caution and pending housing arrangements to be made on Monday. While on Psych Observation, he will be seen daily by Psychology. Completed by PsyD on 07/28/2019 09:24 Generated 07/28/2019 09:24 by PsyD Bureau of Prisons - NYM SDNY_00017454 Fage 1 of 1 EFTA00139091 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/27/2019 07:14 Provider: PsyD Reg #: 76318-054 Unit Team: 5 Focus of Session He was seen by writer while he was on Psych Observation. Subjective/Objective Presentation The "Eating/Shower Chart' indicated yesterday he ate dinner, drank liquids, and took a shower when offered. The Psych Observation Log noted he brushed his teeth, went to a Legal visit, talked about business and investing to an Inmate Companion, ate, and slept. When interviewed, he stated he still cannot remember what happened in SHU that caused the marks on his neck. He stated that for the 5 days before that he had only slept about 30 minutes each night because of noise in SHU. He stated he is anxious about going back to SHU because he stated he is going back to a place where he had gotten marks on his neck and he does not know why it happened. He said he has an appetite and is eating. He said he is waking up every 1 1/2 hours. He stated he feels dehydrated because he is not drinking enough water because he stated he feels he is not given enough bathroom breaks while with his Attorney. Medical was e-mailed with his complaint of feeling dehydrated. He said his Lawyers and friends are all emotionally supportive. Current Mental Status: He exhibited a neutral mood with a full range of affect. His speech was logical and coherent, with no loosening of associations or tangential, circumstantial or irrelevant speech. Auditory and visual hallucinations were denied, and delusions were not elicited. He did not engage in any bizarre or inappropriate behavior. He denied current suicidal or self harm ideation. He stated "I'm a coward." He added he does not like pain and even does not like when he has to give blood. He agreed to immediately tell staff and Inmate Companions if he starts to have suicidal or self harm thoughts. He was future oriented. He does not appear to be an immediate danger to self. He denied thoughts of hurling others and he agreed to tell staff and Inmate Companions if he has these thoughts. fntervention(s) Supportive and educative interventions were provided. Turning Points handouts on stress management, sleep, and building a routine in SHU were placed on his cell door to be given to him when his food slot is opened. He stated he wants it noted in his chart that he is being given a pamphlet on sleep, but that is not going to help because of the noise in SHU that prevents him from sleeping. Progress/Plan He will remain on Psych Observation in an abundance of caution and pending housing arrangements to be made on Monday. While on Psych Observation, he will be seen daily by Psychology. Completed by PsyD on 07/28/2019 09:19 Generated 07/28/2019 09:19 by PsyD Bureau of Prisons - NYM SDNY_00017455 Fage 1 of 1 EFTA00139092 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/27/2019 07:14 Provider: PsyD Reg #: 76318-054 Unit Team: 5 Focus of Session He was seen by writer while he was on Psych Observation. Subjective/Objective Presentation The "Eating/Shower Chart" indicated yesterday he ate dinner, drank liquids, and took a shower when offered. The Psych Observation Log noted he brushed his teeth, went to a Legal visit, talked about business and investing to an Inmate Companion, ate, an When interviewed, he st stated that for the 5 days ti he is anxious about going bac neck and he does not know why II cannot remember what happened in SHU that caused the marks on his neck. He e had only slept about 30 minutes each night because of noise in SHU. He stated ecause he stated he is going back to a place where he had gotten marks on his He said he has an appetite and is eats He said is waking up every 1 1/2 hours. He stated he feels dehydrated because he is not drinking enough water tated he feels he is not given enough bathroom breaks while with his Attorney. Medical was e-mailed with his f feeling dehydrated. He said his Lawyers and friends are all emotionally supportive. Current Mental Status: He exhibited a neutral mood ly full range of affect. His speech was logical and coherent, with no loosening of associations or tangential ntial or irrelevant speech. Auditory and visual hallucinations were denied, and delusions were not elicited. n engage in any bizarre or inappropriate behavior. He denied current suicidal or self harm ideation. He stated " ." He added he does not like pain and even does not like when he has to give blood. He agreed to immedia t aff and Inmate Companions if he starts to have suicidal or self harm thoughts. He was future oriented. He do o be an immediate danger to self. He denied thoughts of hurting others and he agreed to tell staff and lnmat s if he has these thoughts. Jntervention(s) Supportive and educative interventions were provided. He was given TurninrP douts on stress management, sleep, and building a routine in SHU. He stated he wants it noted in his chart th given a pamphlet on sleep, but that is not going to help because of the noise in SHU that prevents him Progress/Plan He will remain on Psych Observation in an abundance of caution and pending housing arr be made on Monday. While on Psych Observation, he will be seen daily by Psychology. Completed by PsyD on 07/27/2019 08:16 Generated 07/27/2019 08:16 by PsyD Bureau of Prisons - NYM SDNY_00017466 Fape 1 of 1 EFTA00139093 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/27/2019 07:14 Provider: PsyD Reg #: 76318-054 Unit Team: 5 Focus of Session He was seen by writer while he was on Psych Observation. Subjective/Objective Presentation The "Eating/Shower Chart' indicated yesterday he ate dinner, drank liquids, and took a shower when offered. The Psych Observation Log noted he brushed his teeth, went to a Legal visit, talked about business and investing to an Inmate Companion, ate, an When interviewed, he st stated that for the 5 days b he is anxious about going bac neck and he does not know why II cannot remember what happened in SHU that caused the marks on his neck. He e had only slept about 30 minutes each night because of noise in SHU. He stated ecause he stated he is going back to a place where he had gotten marks on his He said he has an appetite and is eati He said is waking up every 1 1/2 hours. He stated he feels dehydrated because he is not drinking enough water tated he feels he is not given enough bathroom breaks while with his Attorney. Medical was e-mailed with his f feeling dehydrated. He said his Lawyers and friends are all emotionally supportive. Current Mental Status: He exhibited a neutral mood ly full range of affect. His speech was logical and coherent, with no loosening of associations or tangential ntial or irrelevant speech. Auditory and visual hallucinations were denied, and delusions were not elicited. n engage in any bizarre or inappropriate behavior. He denied current suicidal or self harm ideation. He stated " ." He added he does not like pain and even does not like when he has to give blood. He agreed to immedia t aff and Inmate Companions if he starts to have suicidal or self harm thoughts. He was future oriented. He do o be an immediate danger to self. He denied thoughts of hurting others and he agreed to tell staff and Inmat s if he has these thoughts. fntervention(s) Supportive and educative interventions were provided. He was given TurninrP douts on stress management, sleep, and building a routine in SHU. He stated he wants it noted in his chart th given a pamphlet on sleep, but that is not going to help because of the noise in SHU that prevents him Progress/Plan He will remain on Psych Observation in an abundance of caution and pending housing arr be made on Monday. While on Psych Observation, he will be seen daily by Psychology. Completed by PsyD on 07/27/2019 08:16 Generated 07/27/2019 08:16 by PsyD Bureau of Prisons - NYM SDNY_00017467 Fape 1 of 1 EFTA00139094 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: 07/27/2019 07:14 Facility: NYM Amendment made to this note by PsyD on 07 28 2019 09:19. Bureau of Prisons - NNW SDNY_00017458 EFTA00139095 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/26/2019 09:09 Provider: PhD/Chief Reg #: 76318-054 Unit Team: 5 Focus of Session Inmate Epstein was seen while on psychological observation in our hospital area. Subjective/Objective Presentation Prior to this writer's contact with him, Inmate Epstein showered and dressed himself for his legal visit today. He was smiling and did crack some jokes during the interview. He did elucidate some complaints and suggested being disappointed with this writer as he wants 'to trust me and for me to trust him." He stated he remains unhappy with legal visiting procedures as he cannot go to the bathroom as frequently as he would like to since he has a "weak bladder." Inmate Epstein also reported since coming to the psychological observation area, he has felt constipated and needs his Colace. He had self-carry Colace in SHU, but since coming to the observation area, he has not had his medication. This writer immediately notified medical and his pills were being processed during the interview. Inmate Epstein also continues to complain about the conditions of SHU confinement (i.e., feeling punished, smells, noise, and restrictions). With regard to the events which lead to his initial placement on suicide watch, inmate Epstein stated he has no memory of the event. He asked to speak with his old cellmate "Nick" to see if he can tell him what happened or see if his memory could be triggered. He remarked, "I am still trying to figure out how I got this (pointing to the scab around his neck)." Inmate Epstein denies remembering harming himself and/or being harmed by his cellmate. He does not exhibit symptoms of any cognitive disorder, seizure disorder, psychotic disorder, or dissociative disorder at this time or in the past. Inmate Epstein denied any current suicidal ideation, intention, or plan. He reported wanting to be alive to fight his legal case and go back and live life. He referred to himself as "a coward" and "I'm Jewish." He said he is not the type who likes pain or would ever attempt to harm himself. While on psychological observation, inmate Epstein has been eating his meals, sleeping and interacting with the inmate companions. He is in legal visiting the majority of the day and in the evenings. His log book and eating/shower chart reflect the same. He has been speaking to inmate companions about investment strategies and about prison adjustment. Correctional Staff report during his legal visits, he is interacting with his attorney, animated, laughing, and joking. Intervention(s) Inmate Epstein was provided with supportive and coping skills interventions today. He was receptive to them, but mostly wanted to express his complaints about his current prison confinement status and needs. He wanted this writer to address them. Progress/Plan Inmate Epstein will remain on psychological observation in an abundance of caution and pending housing arrangements to be made on Monday. He continues to be vague and reports memory deficits regarding the events which lead to a piece of sheet being placed loosely around his neck and marks with scabs around his neck. Completed by PhD/Chief Psychologist on 07/26/2019 10:05 Generated 07/26/2019 10:05 by PhDiChiel Bureau of Prisons - NYM SDNY_00017459 Fape 1 of 1 EFTA00139096 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/25/2019 10:14 Provider: PhD/Chief Reg #: 76318-054 Unit Team: 5 Focus of Session Inmate Epstein was seen by this writer this morning while on psychological observation in the hospital area of the prison. Subjective/Objective Presentation Inmate Epstein was in good spirits today and engaged in reciprocal conversation with this writer this morning. He smiled and remarked, "welcome back" when this writer arrived. He continues to assert he does not remember how he received marks around his neck, remarking "I do not remember anything, maybe you can give me some cues." He stated he just remembers going for a drink of water and the next thing he knew he woke up to the sound of his own snoring. When this writer attempted to get a more detailed account from him, indicating that it would be rare to have such impairments in memory as he does not suffer from an acute cognitive disorder, he smiled and said he understood my position. Inmate Epstein did reveal he is unhappy with his current confinement in Special Housing (SHU) as he considers it "a punishment cell? He said he finds the restrictions up there unfair as he has not done anything wrong. Inmate Epstein stated he feels it is dangerous in the SHU, he cannot sleep well up there due to noise from the other inmates, it smells, and it is difficult for him to work on his legal case up there. He stated he has not received the phone calls he was promised nor has he been able to receive recreation. It was explained to him that he spends the entire day in the attorney conference room and it is likely that he has missed the times when staff members have attempted to give him phone calls and recreation. Inmate Epstein also reported complaints about the attorney conference room, stating they do not take him to the bathroom frequently enough. Inmate Epstein adamantly denied any suicidality at this time, stating 'I am too vested in my case to fight it, I have a life and I want to go back to living my life." He denied any acute symptoms at this time. According to his log book, he has been eating, drinking, sleeping, and interacting with the inmate companions. He has also been attending his daily legal visits. Intervention(s) Inmate EPSTEIN was provided with brief supportive interventions and psychoeducation regarding additional coping strategies. Inmate EPSTEIN was mostly receptive to these interventions. He requested to be housed in general population rather than the SHU and stated he wanted to remain on psychological observation due to his concerns with being in the SHU. Progress/Plan In an abundance of caution, inmate Epstein will remain on psychological observation. He has yet to give an account of how he sustained the marks around his neck, is not revealing much about his mental status, and there are concerns about his adjustment at this time to being housed in the SHU. Inmate Epstein will be seen daily by psychology while on psychological observation. Completed by PhD/Chief Psychologist on 07/25/2019 10:43 Generated 07125/2019 10:43 by PhD/Chief Bureau of Prisons - NYM SDNY_0001700 rage 1 of 1 EFTA00139097 Bureau of Prisons Psychology Services Post Suicide Watch Report "SENSITIVE BUT UNCLASSIFIED— Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: 5 Date: 07/24/2019 09:23 Provider: DiMisa, Samantha Ph.D. Watch Start Date: 07/23/2019 01:40 Total Time on Watch: 31 hrs 5 minutes Watch Conducted By: Both inmates and staff Current Mental Status Watch Stop Date: 07/24/2019 08:45 Transfered to Medical Center: No 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 Current Mental Status: Mr. EPSTEIN was alert and oriented. He was polite, calm, and cooperative in demeanor. He exhibited a neutral affect with appropriate range. Eye contact and hygiene were appropriate. The inmate spoke with normal rate, tone, and volume. His thoughts were organized and coherent, with no loosening of associations or tangential, circumstantial, or irrelevant content. There was no evidence of perceptual disturbance, delusional ideation, or a formal thought disorder. He did not engage in any bizarre or inappropriate behavior. He noted having normal sleeping and eating habits. Mr. EPSTEIN explicitly denied recent and current suicidal ideation, planning, and intent. He was future-oriented and expressed a commitment to life and safety, agreeing to contact staff immediately should he experience suicidal ideation or psychological distress. He also denied thoughts of harming others. Risk Factors Assessed* This writer screened the inmate for a variety of empirically validated factors commonly associated with risk for self harm. The following STATIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related behaviors: High Profile Crime, Lack of family connections, Sex offender status The following DYNAMIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related behaviors: Current physical pain, Fear for own safety The following PROTECTIVE factors were assessed to be present and may decrease the inmate's risk of suicide:Able to identify reasons to live, Adequate problem solving skills, Denial of suicidal ideation/intention/plans, Future orientation, View of death as negative, Willingness to engage in treatment Risk Factors: Mr. EPSTEIN has a significant scar around his neck, which is now scabbing over. He reported swelling in this area but denied experiencing any related pain. Mr. EPSTEIN continues to claim a lack of memory for the incident resulting in this scar. The story he provided was vague, such that this writer challenged him a couple of times, but he insisted he was being honest about his lapse in memory. The nature of the incident remain unclear. Mr. EPSTEIN is incarcerated for a very high profile crime with media attention. He was recently denied bail. He also reported difficulty managing his time in the SHU. He reported being fearful for his safety if he is to return to the cell with his previous cell mate. Protective Factors: Mr. EPSTEIN adamantly denied current suicidal ideation or intent or a history of suicide attempts. He stated, "I have no interest in killing myself." He explained, although his situation is "not perfect" due to his being incarcerated, he noted he has "lots to do for [his) legal case." He described having a "wonderful life," to include interactions with "interesting people and projects." He said "it would be crazy" to take his life. He furthered, "I would not do that to myself." He denied feelings of hopelessness, although did report being "depressed" and "unhappy" about his current legal situation. He previously denied a history of childhood abuse. He reported he is sleeping adequately now that he is no longer in the SHU. He appear future-oriented as he endorsed an interest in being housed in general population. Weighing of Risk and Protective Factors: Mr. EPSTEIN adamantly denied sucidality. However, in light of his vague self-report regarding the incident which precipitated his placement on Suicide Watch, combined with his fear for his gyos3bblymteported Generated 07/24/2019 12:09 by DiMisa. Samantha Ph.D. Bureau of Prisons Page 1 of 3 EFTA00139098 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: 5 Date: 07/24/2019 09:23 Provider: DiMisa, Samantha Ph.D. difficulty managing his time in the SHU, and the high profile nature of his alleged offense, Mr. EPSTEIN will be stepped down from Suicide Watch to Psychological Observation. Changes in Risk Factors Assessed Upon a review of the log book, it was indicated Mr. EPSTEIN has been speaking to the inmate companions about having previously taught mathematics and physics. He has been observed pacing the cell as well as sleeping, eating. and drinking within normal limits. Upon interview today, Mr. EPSTEIN requested he be provided a toothbrush as well as a shower. His requests were made known to the lieutenants and he was provided a shower prior to attending his legal visit. This writer also provided him a toothbrush, toothpaste, and hygiene products. Asked about the alleged incident which transpired yesterday resulting in his placement on Suicide Watch, Mr. EPSTEIN said he is frustrated he has been placed in a "punishment cell for no reason." Specifically, Mr. EPSTEIN was referring to his placement in the SHU. Asked to recall the events surrounding the alleged incident, Mr. EPSTEIN said his cell mate was "playing with a bed sheet" and he claimed he does not recall the events thereafter. He said he recalled eating meat and drinking water and claimed the next event for which he has memory is his hearing himself snore and waking up on a stretcher. Mr. EPSTEIN claimed he does not recall himself or his cell mate tying a string or rope around his neck. He said he has "been trying to remember" and "wracking his mind." Asked if he experienced any interpersonal issues with his cell mate, Mr. EPSTEIN described his cell mate as "agitated" and claimed his cell mate called him a "pedophile" for the first time yesterday. His cell mate was also reportedly reading a newspaper article about Mr. EPSTEIN, which bothered him and it was something he believed to be "strange" for their to be an article about him in his cell. Mr. EPSTEIN recalled throwing away the newspaper photograph of himself by crumpling it and flushing it down the toilet. Asked if his cell mate ever threatened to harm him, he denied this to be the case. Asked why he told the inmate companions yesterday his cell mate tried to kill him, while also claiming no memory of the incident, Mr. EPSTEIN again said he did not recall the incident and further stated, "I don't know if he put it there as a joke." Mr. EPSTEIN explained he had been experiencing difficulty sleeping in his SHU cell due to his inmate peers banging on the cell door and window, but has not been experiencing any other acute issues other than this. Reason for Removal from Watch Mr. EPSTEIN stated, "I have no interest in killing myself? He explained although his situation is "not perfect" due to his being incarcerated, he noted he has "lots to do for [his] legal case." He described having a "wonderful life," to include interactions with "interesting people and projects? He said "it would be crazy" to take his life. He furthered, "I would not do that to myself." Mr. EPSTEIN did express a feeling of safety being housed on Psychological Observation rather than in the SHU. He asked if he could remain on this status for a couple of days. he was advised his housing situation will be re-evaluated on a day-to-day basis. He expressed a desire to be housed in general population rather than in the SHU and asked if there were a "safer" unit for him to be housed in comparison to the one where he was initially placed. Mr. EPSTEIN claimed there were many MS-13 gang members on the initial unit. He was advised he will be maintained on Psychological Observation in the near future, but his long-term housing situation will be revisited, as it is not ideal for one to remain in isolation on Psychological Observation for extended periods of time. Mr. EPSTEIN acknowledged this information and thanked this writer for her explanation and time. Diagnosis• No Diagnosis, No Dx - Current Conclusions The Overall Acute Suicide Risk for this Inmate is: Low Overall Chronic Suicide Risk for this Inmate is: Absent Recommendations 1. Mr. EPSTEIN will be removed from Suicide Watch and stepped down to Psychological Observation. 2. While on Psychological Observation, he will be continuously observed by Inmate Companions. 3. While on Psychological Observation, he will be seen daily by Psychology. 4. Supportive and educative interventions were provided. 5. Mr. EPSTEIN was provided novels and a request was made for his legal paperwork to be provided to btrripilAbSnitological Generated 07/24/2019 12:09 by DiMisa. Samantha Ph.D. Bureau of Prisons - NYM Page 2 of 3 EFTA00139099 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: 5 Date: 07/24/2019 09:23 Provider: DiMisa, Samantha Ph.D. Observation. 6. This writer contacted the Pharmacy to indicate Mr. EPSTEIN has not been receiving his medication used to alleviate his constipation. 7. Mr. EPSTEIN attended a legal visit today, after having been provided a shower. 8. Mr. EPSTEIN was educated about both routine and emergency procedures for contacting psychology. 9. The inmate was encouraged to reach out for PRN services should he experience any psychological distress. Completed by DiMisa, Samantha Ph.D. on 07/24/2019 12:09 SDNY_00017463 Generated 07/24/2019 12:09 by DiMisa. Samantha Ph.D. Bureau of Prisons • NYM Page 3 of 3 EFTA00139100 Bureau of Prisons Psychology Services Suicide Risk Assessment "SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facilit : NYM Date: 07/23/2019 10:09 Provider: PsyD Reg #: 76318-054 Unit Team: 5 Type of Housing: SHU- Administrative Segregation Cell Accommodation: Double-Cell FINDINGS This assessment and the resulting recommendations are based on the following sources of information: Clinical Interview, Medical Record, Psychology Data System, Sentry Reason for Referral The On Call Psychologist, Dr. had been contacted by the Operations Lt. at about 2 AM on 7/23/19 to inform her that Mr. Epstein was being placed on Suicide Watch because he was found with a string around his neck. Mr. Epstein was seen by this writer for a Suicide Risk Assessment at about 9:10 AM on 7/23/19. This note is being entered at about 3:35 PM on 7/23/19. Mental Health History According to a Suicide Risk Assessment dated 7/09/19 by Dr. "Inmate Epstein denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time: Self-Harm History According to a Suicide Risk Assessment dated 7/09/19 by Dr. "Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in the past." Substance Abuse History According to a Suicide Risk Assessment dated 7/09/19 by Dr. "Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol." Current Problem Earlier this morning Mr. Epstein was found by SHU staff in his cell with a string loosely tied around his neck. It is unclear at this time if Mr. Epstein had placed the string around his own neck. When Mr. Epstein was asked by this writer how he ended up on Suicide Watch, he denied remembering. He stated he got a drink of water last night in his cell and went back to bed. He said the next thing he remembered is hearing himself snore. He said he wants to know why he is on Suicide Watch. He was informed that staff stated he was found in his cell with a string on his neck. According to Medical records, he had been seen by Medical for this and had a rule out of self inflicted injuries. When this writer reviewed the Staff Suicide Watch Log, it noted that Mr. Epstein told the staff watching him that his cellmate tried to kill him, which Mr. Epstein did not tell this writer when this writer had interviewed Mr. Epstein. This writer was not able to ask Mr. Epstein about this, since Mr. Epstein was now in Legal. The Captain was notified about this notation and the Captain stated they were already aware of this statement. Current Mental Status Level of Consciousness: Alert and Oriented Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content SDNY 00017464 Generated 07/23/2019 15:38 by PsyD Bureau of Prisons - NYM — Page 1 of 3 EFTA00139101 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M F ili : NYM Date: 07/23/2019 10:09 Provider: PsyD Reg ff: 76318-054 Unit Team: 5 Thought Process: Goal Directed Thought Content: Normal Current Mental Status: He exhibited a neutral mood with a full range of affect. His speech was logical and coherent, with no loosening of associations or tangential, circumstantial or irrelevant speech. Auditory and visual hallucinations were denied, and delusions were not elicited. He did not engage in any bizarre or inappropriate behavior. He denied current suicidal or self harm ideation and he agreed to immediately tell staff if he starts to have suicidal or self harm thoughts. He was future oriented. He does not appear to be an immediate danger to self. He denied thoughts of hurting others and he agreed to tell staff if he has these thoughts. RISK AND PROTECTIVE FACTORS ASSESSED. This writer screened the inmate for a variety of empirically validated factors commonly associated with risk for self-harm and suicide. The following STATIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related behaviors: High Profile Crime, Lack of family connections, Sex offender status The following DYNAMIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related behaviors: Current physical pain The following PROTECTIVE factors were assessed to be present and may decrease the inmate's risk of suicide:Able to identify reasons to live, Adequate problem solving skills. Denial of suicidal ideation/intention/plans, Future orientation, View of death as negative, Willingness to engage in treatment Risk Factors: He was found by staff in his cell in SHU with a string loosely tied around his neck, which Mr. Epstein stated he did not remember anything about. It is unclear at this time if Mr. Epstein had placed the string around his own neck or if someone else did. According to Medical, he had a circular line around the base of his neck, which he denied knowing how he obtained. He stated his throat hurts which was reported to Medical. He has a high profile sex offense case and recently was denied bail. When asked if he has any friends or family that are emotionally supportive, he stated he does not know what that means. When emotional supports were explained to him and then again asked if he as any family or friends that are emotionally supportive, he was vague and said he has a lot of people. Protective Factors: He denied current suicidal or self harm thoughts or ever having these thoughts. He denied a history of self harm and suicide attempts. He denied a family history of suicidal and self harm attempts. He denied having any chronic medical conditions. He denied feeling hopeless. He denied a history of childhood abuse. He denied fearing for his safety. He denied feeling like a burden to anyone. He reported he is sleeping adequately. He stated he lives to have fun, to enjoy life, and to leam. He said his future plans include fighting his case and going back to his normal life. Whereas, he is denying suicidal and self harm thoughts and has a lot of protective factors, he is denying that he remembers how he ended up on Suicide Watch and has marks encircling his neck. It is unclear at this time if he had placed the string around his neck or if someone else did. He will remain on Suicide Watch for further observation and safekeeping. DIAGNOSIS; No Diagnosis, No Dx - Current CONCLUSIONS The Overall Acute Suicide Risk for this Inmate is: Moderate Overall Chronic Suicide Risk for this Inmate is: Absent RECOMMENDATIONS 1. Mr. Epstein will remain on Suicide Watch for further observation and safekeeping. 2. While on Suicide Watch, he will be continuously observed by Inmate Companions. 3. While on Suicide Watch, he will be seen daily by Psychology. 4. Supportive and educative interventions were provided. 5. Medical was informed that he reported his throat hurts. Suicide Watch: A suicide watch was initiated by non-clinical staff and continues to be warranted Suicide Watch was initiated on: 07/23/2019 01:40 Generated 07/23/2019 15:38 by PsyD Bureau of Prisons - NYM SDNY 00017465 — Page 2 of 3 EFTA00139102 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facilit : NYM Date: 07:23.2019 10:09 Provider: PsyD Reg #: 76318-054 Unit Team: 5 Completed by PsyD on 07/23/2019 15:38 SDNY 00017466 Generated 07/23/2019 15:38 by PsyD Bureau of Prisons NYM - Page 3 of 3 EFTA00139103 Bureau of Prisons Psychology Services General Administrative Note "SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/23/2019 07:56 Provider: PhD/Chief Reg #: 76318-054 Unit Team: 5 Comments This On-Call Psychologist was contacted by the Operations Lt. at about 2 AM on 7/23/19 to inform Mr. Epstein was being placed on Suicide Watch because he was found with a string loosely hanging around his neck. Mr. Epstein will be seen today by the duty psychologist for a Suicide Risk Assessment. Completed by PhD/Chief Psychologist on 07/24/2019 07:59 Generated 07/24/2019 07:59 by PhD/Chief Bureau of Prisons - NYM SDNY_00017467 Fape 1 of 1 EFTA00139104 Bureau of Prisons Psychology Services SHU Review "SENSITIVE BUT UNCLASSIFIED— Inmate Name: Date of Birth: Date: EPSTEIN, JEFFREY EDWARD 01/20/1953 Sex: M 07/18/2019 07:21 Provider: Facility NYM PhD/Chief Reg #: 76318-054 Unit Team: A&O Placed in SHU: Status: Basis of Review: Mental Status: 07/10/2019 ADMIN.DETENTION Inmate was interviewed No significant mental health issues. Type: Threat to Self: Adjustment: Threat to Others: SHU Low Satisfactory, segregation not detrimental Low Comments Monthly SHU Review Note Inmate Epstein was meeting with his legal team today and has a court hearing. He was not able to be seen for a SHU review. Another attempt to interview him for a SHU review will be done in the near future. Completed by PhD/Chief Psychologist on 07/18/2019 12:06 SDNY_00017468 Generated 07/1812019 12:06 by PhD/Chief Bureau of Prisons - NYM Page 1 of 1 EFTA00139105 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/16/2019 12:48 Provider: PhD/Chief Reg #: 76318-054 Unit Team: A&O Focus of Session Inmate Epstein called for this writer in attorney conference today. The officer in attorney conference notified this writer that he was asking to be seen. Subjective/Objective Presentation Inmate Epstein reported he has not received a spoon or soap in SHU, nor did he receive the phone calls that were "promised to him: He told this writer we need to have mutual trust that his needs are met in the prison. This writer told inmate Epstein that she would address his concerns. On the way out, a staff member told this writer she witnessed inmate Epstein receive two phone calls from the Li Nonetheless, this writer informed the SHU lieutenant of his concerns and he said he would ensure that he had soap, a spoon, and his initial SHU phone call. Inmate Epstein did not have any psychological concerns today. He denied any mental health symptoms or suicidality. He has been eating as best as he can and has requested a Kosher diet. Jntervention(sj Inmate EPSTEIN was provided with brief supportive and psychoeducation regarding additional coping strategies. Inmate EPSTEIN was receptive to these interventions. He continued with his legal visit. Progress/Plan Inmate EPSTEIN was educated about both routine and emergency procedures for contacting Psychology staff. He was reminded of the self-help books and audiotapes available through the Psychology department. There appears to be no need for follow up at this time. He will be seen in SHU for rounds and monthly SHU reviews. Completed by PhD/Chief Psychologist on 07/18/2019 13:05 Generated 07/18/2019 13:05 by PhD/Chief Bureau of Prisons - NYM SDNY_00017469 Fape 1 of 1 EFTA00139106 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/11/2019 15:21 Provider: PhD/Chief Reg #: 76318-054 Unit Team: A&O Focus of Session Inmate Epstein was seen for his psychological observation follow-up in attorney conference this afternoon. Subjective/Objective Presentation Inmate Epstein reported he has been consulting with his attorney most of the day. He elucidated concerns about his incarceration including not receiving his property yet in SHU, feeling cold in his cell, not receiving his Colace, not having enough water in attorney conference, and a desire to recreate in SHU.' Inmate Epstein was also upset about wearing an orange jumpsuit and being treated like "a bad guy" when he did not do anything wrong in the prison. Custody and security concerns were addressed with inmate Epstein including why he has to wear his orange jumpsuit (due to his being housed in SHU). He requested that he be placed in a brown uniform during his legal visits. He was told his concerns would be addressed in the SHU meeting. Inmate Epstein stated he is not having any current problems with his cellmate and indicated he at bran cereal for breakfast and took a shower yesterday. He did not sleep well last night. Inmate Epstein continues to deny any suicidal ideation, intention or plan. He did not appear to be in any distress at this time. fntervention(s) Inmate EPSTEIN was provided with brief supportive interventions, CBT-based interventions, and psychoeducation regarding additional coping strategies. Inmate EPSTEIN was receptive to these interventions. Progress/Plan Inmate EPSTEIN was educated about both routine and emergency procedures for contacting Psychology staff. He was reminded of the self-help books and audiotapes available through the Psychology department. He will be seen next week after his bail hearing to assess his mental status and psychological stability. Completed by PhD/Chief Psychologist on 07/12/2019 07:51 Generated 07/12/2019 07:51 by PhD/Chiel Bureau of Prisons - NYM SDNY_00017470 Far 1 of 1 EFTA00139107 Bureau of Prisons Psychology Services General Administrative Note "SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/11/2019 14:28 Provider: PsyD Reg #: 76318-054 Unit Team: A&O Comments This writer attempted to see Mr. Epstein in the morning and then again in the afternoon for a Psych Observation Follow Up, but he was in Attorney Conference. Completed by PsyD on 07/11/2019 15:51 Generated 07/11/2019 15:51 by PsyD Bureau of Prisons • NYM SDNY_00017471 rage 1 of 1 EFTA00139108 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/10/2019 08:38 Provider: PhD/Chief Reg #: 76318-054 Unit Team: A&O Focus of Session Inmate Epstein was seen today for a psychological observation contact in the hospital area by this writer. Subjective/Objective Presentation Inmate Epstein appeared well and it was noted in his log book and eating/sleeping chart that he has been eating his meals, sleeping, interacting with the inmate companions, and pacing in his cell. Today, he presented this writer with numerous concerns and requests. He stated he does not want to be housed in the SHU because he is not comfortable there; he wants to be single-celled if he goes to the SHU; he wants Colace, not the Ducolex he received from medical yesterday; he wants to be able to walk around and go to recreation; he does not want to wear an orange uniform to his legal visits because he is treated like a punished inmate;" he wants a phone call before he leaves the psychological observation area; he wants a shower and towel; he would like to be housed in the cadre (5S) unit; and would like his property, paper, and a pen. Inmate Epstein's concerns were addressed by this writer and it was explained to him he will not be single-celled or placed in a housing unit for safety and security concerns. His medical concerns (constipation) were discussed with health services as well as his desire to be placed on Colace. Inmate Epstein was provided a shower this morning. intervention(s1 Inmate Epstein was provided with supportive intervention and coping skills strategies today. He was receptive to interventions and was able to elucidate his various needs. He did not present with any acute psychopathology and continues to deny any suicidal ideation, intention, or plan. He is looking forward to his bail hearing on Monday but stated he is aware that even if he gets bail, it will take at least two weeks to sort things out so he can leave the jail. Progress/Plan Inmate Epstein is not in any psychological distress, does not present with any mental health symptoms or complaints, and is denying any suicidally. He appears psychologically stable at this time and can be released from the psychological observation area. Inmate Epstein will be housed in the 9S area with a cellmate. He will be seen again tomorrow by psychology to evaluate his mental status and psychological stability. Completed by PhD/Chief Psychologist on 07/10/2019 09:09 Generated 07/10/2019 09:09 by PhD/Chief Bureau of Prisons - NYM SDNY_00017472 Fape 1 of 1 EFTA00139109 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services Diagnostic and Care Level Formulation Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/09/2019 10:13 Provider: PhD/Chief Reg #: 76318-054 Unit Team: A&O Relevant Historical Information Inmate Epstein is a 66-year-old Caucasian male, currently incarcerated on sex trafficking charges. He denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time. Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in the past. Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol. Presenting Problem/Symptom Inmate Epstein was seen by this writer for suicide risk assessment today, 7/9/19 at 7:30 a.m. for precautionary reasons. He returned from court yesterday evening. He did not mark any mental health items or symptoms on his Psychology Questionnaire (PSIQ) when he entered the institution. Nonetheless, Inmate Epstein has various risk factors for suicidality including a high profile case with media attention, sex offense/trafficking charges, pre-trial status, and he had a court proceeding yesterday which could have given him bad news regarding his legal situation. Inmate Epstein returned from court after duty hours yesterday evening and staff notified the on-call psychologist. Inmate Epstein was placed on a precautionary psychological observation status until psychology could interview him this morning to conduct a formal suicide risk assessment in order to determine whether he is currently at-risk for suicidality. Diagnostic Formulation Inmate Epstein has no history of mental health problems and does not exhibit suicidality at this time. He has never received inpatient or outpatient mental health treatment and denied any history of suicidality. Currently, he does not exhibit any acute psychopathology, is currently psychologically stable and iS in no psychological distress. As such, he is being classified as a CC1-MH inmate at this time. CARE1-MH is indicative of an inmate who either has no identifiable mental illness (Axis I 'No Diagnosis") or is mildly ill and requires clinical intervention on an as-needed basis. Care Level Formulation CARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention. Diagnosis: No Diagnosis, No Dx - Current Completed by PhD/Chief Psychologist on 07/09/2019 10:40 Generated 07109/2019 10:40 by PhD/Chiel Bureau of Prisons - NYM SDNY_00017473 Fape 1 of 1 EFTA00139110 Bureau of Prisons Psychology Services Diagnostic and Care Level Formulation "SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Date: 07/09/2019 10:13 Provider: M Facility: NYM PhD/Chief Reg #: 76318-054 Unit Team: A&O Relevant Historical Information Inmate Epstein is a 66-year-old Caucasian male, currently incarcerated on sex trafficking charges. He denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time. Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in thgpast. Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink Inmate Epstein was seen health items or symptoms on h Epstein has various risk factors charges, pre-trial status, and he had legal situation. Inmate Epstein return psychologist. Inmate Epstein was placed on interview him this morning to conduct a for suicidality. Diagnostic Formulation Inmate Epstein has no history of mental health proble s not exhibit suicidality at this time. He has never received inpatient or outpatient mental health treatment 1any history of suicidality. Currently, he does not exhibit any acute psychopathology, is currently psychologic nd is in no psychological distress. As such, he is being classified as a CC1-MH inmate at this time. CARE1-M e of an inmate who either has no identifiable mental illness (Axis I "No Diagnosis") or is mildly ill and requires ni Jention on an as-needed basis. Care Level Formulation 'sk assessment today for precautionary reasons. He did not mark any mental ology Questionnaire (PS1O) when he entered the institution. Nonetheless, Inmate y including a high profile case with media attention, sex offense/trafficking proceeding yesterday which could have given him bad news regarding his om court er duty hours yesterday evening and staff notified the on-call onary psychological observation status until psychology could risk assessment to determine whether he is currently at-risk for CARE1-MH is indicative of an inmate who shows no significant level of illness and demonstrates no need for regular mental health intervention. Diagnosis: No Diagnosis, No Dx - Current Completed by PhD/Chief Psychologist on 07/09/2019 10:32 airment associated with a mental Generated 07/09/2019 10:32 by PhD/Chief Bureau of Prisons - NYM SDNY_00017474 Fape 1 of 1 EFTA00139111 Bureau of Prisons Psychology Services Diagnostic and Care Level Formulation "SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Date: 07/09/2019 10:13 Provider: M Facility: NYM PhD/Chief Reg #: 76318-054 Unit Team: A&O Relevant Historical Information Inmate Epstein is a 66-year-old Caucasian male, currently incarcerated on sex trafficking charges. He denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time. Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in thgpast. Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink Inmate Epstein was seen health items or symptoms on h Epstein has various risk factors charges, pre-trial status, and he had legal situation. Inmate Epstein return psychologist. Inmate Epstein was placed on interview him this morning to conduct a for suicidality. Diagnostic Formulation Inmate Epstein has no history of mental health proble s not exhibit suicidality at this time. He has never received inpatient or outpatient mental health treatment 1any history of suicidality. Currently, he does not exhibit any acute psychopathology, is currently psychologic nd is in no psychological distress. As such, he is being classified as a CC1-MH inmate at this time. CARE1-M e of an inmate who either has no identifiable mental illness (Axis I 'No Diagnosis") or is mildly ill and requires ention on an as-needed basis. Care Level Formulation 'sk assessment today for precautionary reasons. He did not mark any mental ology Questionnaire (PS1O) when he entered the institution. Nonetheless, Inmate y including a high profile case with media attention, sex offense/trafficking proceeding yesterday which could have given him bad news regarding his om court er duty hours yesterday evening and staff notified the on-call onary psychological observation status until psychology could risk assessment to determine whether he is currently at-risk for CARE1-MH is indicative of an inmate who shows no significant level of illness and demonstrates no need for regular mental health intervention. Diagnosis: No Diagnosis, No Dx - Current Completed by PhD/Chief Psychologist on 07/09/2019 10:32 airment associated with a mental Generated 07/09/2019 10:32 by PhD/Chief Bureau of Prisons - NYM SDNY_00017475 Page 1 of 1 EFTA00139112 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/09/2019 10:13 Facility: NYM Amendment made to this note by PhD Chief Psychologist on 07'09 2019 10:40. SDNV_00017476 EFTA00139113 Bureau of Prisons Psychology Services Suicide Risk Assessment "SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist Type of Housing: Other Psychological Observation Cell Accommodation: Single Cell FINDINGS This assessment and the resulting recommendations are based on the following sources of information: Medical Record, Clinical Interview Inmate Epstein was placed on psychological observation when he returned from court yesterday evening 7/8/19 for precautionary reasons. He is not on a suicide watch at this time. He was seen this morning for a psychological observation contact and suicide risk assessment this morning, 7/9/19, at 7:30 a.m. as it was determined he possessed some at-risk factors for suicidality. Reason for Referral Inmate Epstein is being seen for suicide risk assessment today for precautionary reasons. Inmate Epstein has various risk factors for suicidality at this time including a high profile case with media attention, sex offense/trafficking charges, pre-trial status. and he had a court proceeding yesterday which could have given him bad news regarding his legal situation. As such, this writer instructed R&D staff, as well as the Lieutenant's Office, to immediately notify the psychology department when he returned from court. Inmate Epstein returned from court after duty hours and denied suicidality. The aforementioned staff notified the on-call psychologist and inmate Epstein was placed on a precautionary psychological observation status until psychology could interview him this morning to conduct a suicide risk assessment. Developmental History Inmate Epstein denied any history of being the victim and/or perpetrator of physical or sexual abuse. Educational History/Cognitive Impairment Inmate Epstein reported he obtained his high school diploma and attended some graduate classes in the area of mathematics. Arrest History and Experience of Incarceration Inmate Epstein reported he has served time in Palm Beach County jail on sex offense charges (soliciting prostitution) in the past. He is now being charged with sex trafficking, on a federal level. Mental Health History Inmate Epstein denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time. Self-Harm History Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in the past. Substance Abuse History Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol. Medical Concerns Inmate Epstein denied any significant medical problems, other than a history of high triglycerides. He reported feeling constipated at this time. Current Problem Inmate Epstein is currently on psychological observation due to his having multiple risk factors associated with suicidality. He denies any suicidality at this time and has no mental health or suicide history. He is being seen for a suicide risk assessment in an abundance of caution. Current Mental Status Generated 07/10/2019 09:20 by PhD/Chiel Bureau of Prisons - NYM SDNY 00017477 — Page 1 of 3 EFTA00139114 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M F ili : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist Level of Consciousness: Alert and Oriented Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Inmate Epstein did not exhibit any acute psychopathology and exhibited a clear mental status. Current Mental Status: Mr. EPSTEIN was alert and oriented. He was polite, calm, and cooperative in demeanor. He exhibited a neutral affect with appropriate range. Eye contact and hygiene were appropriate. The inmate spoke with normal rate, tone, and volume. His thoughts were organized and coherent, with no loosening of associations or tangential, circumstantial, or irrelevant content. There was no evidence of perceptual disturbance, delusional ideation, or a formal thought disorder. He did not engage in any bizarre or inappropriate behavior. He noted having normal sleeping and eating habits. Mr. EPSTEIN explicitly denied recent and current suicidal ideation, planning, and intent. He was future-oriented and expressed a commitment to life and safety, agreeing to contact staff immediately should he experience suicidal ideation. RISK AND PROTECTIVE FACTORS ASSESSED. This writer screened the inmate for a variety of empirically validated factors commonly associated with risk for self-harm and suicide. The following STATIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related behaviors: Sex offender status, Lack of family connections, High Profile Crime Of the DYNAMIC risk factors assessed, none were found to be present. The following PROTECTIVE factors were assessed to be present and may decrease the inmate's risk of suicide:Willingness to engage in treatment, View of death as negative, Future orientation, Denial of suicidal ideation/intention/plans, Adequate problem solving skills, Able to identify reasons to live As noted above, Inmate Epstein is a 66-year-old Caucasian male. He has various risk factors for suicidality at this time including a high profile case with extensive media attention, sex offense/trafficking charges, pre-trial status, and he had a court proceeding yesterday which may have given him bad news regarding his legal situation. Inmate Epstein also informed this writer that his only family at this time is his brother, with whom he does not have a close relationship with. Despite these risk factors, inmate Epstein possesses a number of protective factors at this time. Inmate Epstein adamantly denied any suicidal ideation, intention or plan. He was very future oriented and requested a phone call, to meet with his attorney, to take a shower, and to brush his teeth. He was eating his cereal when this writer arrived and said "I have my paper spoon here." He reported he is going to have a bail hearing on Monday and believes he is going to be released from jail. Inmate Epstein reported he is a Banker and has a "big business" in the community and that "being alive is fun." He also revealed he enjoys learning and teaching. He has confidence in his attorney and described him as "competent." Inmate Epstein denied any mental health history or history of suicidality. He also reported none of his family members have mental health histories. Inmate Epstein stated he is a mathematician and took post graduate classes in this area of study. Inmate Epstein stated he has a support system in the community, including friends and other associates. Finally, inmate Epstein demonstrated a good sense of humor and did not appear dysphoric, agitated or anxious. No acute psychopathology was noted. Overall, inmate Epstein has numerous protective factors at this time that outweigh his risk factors for suicidality. He has a positive outlook regarding his legal case, demonstrates no psychiatric symptoms, has no psychiatric or suicide history, and verbalized a desire to be alive at this time and future orientation. DIAGNOSIS; No Diagnosis, No Dx - Current Generated 07/10/2019 09:20 by PhD/Chief Bureau of Prisons - NYM SDNY 00017478 — Page 2 of 3 EFTA00139115 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M F ili : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist CONCLUSIONS The Overall Acute Suicide Risk for this Inmate is: Low Overall Chronic Suicide Risk for this Inmate is: Absent RECOMMENDATIONS Inmate Epstein is currently on psychological observation pending suitable housing placement. In light of his current sex offense charges and extensive media coverage on the television, he will need to be confined in a suitable housing unit. Inmate Epstein will be seen daily while on psychological observation and will be seen for a psychological observation follow-up session once he is released from observation. Inmate Epstein denied the need for psychological intervention, self-help materials, or follow-up. He has been classified as a CC1-MH inmate at this time. CARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention. Suicide Watch: A suicide watch is not warranted at this time Completed by PhD/Chief Psychologist on 07/10/2019 09:20 Generated 07/10/2019 09:20 by PhD/Chief Bureau of Prisons - NYM SDNY 00017479 — Page 3 of 3 EFTA00139116 Bureau of Prisons Psychology Services Suicide Risk Assessment "SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist Type of Housing: Other Psychological Observation Cell Accommodation: Single Cell FINDINGS This assessment and the resulting recommendations are based on the following sources of information: Clinical Interview, Medical Record Inmate Epstein was placed on chological observation when he returned from court yesterday evening 7/8/19 for precautionary reasons. He i a suicide watch at this time. Reason for Referral Inmate Epstein is being seen f e risk assessment today for precautionary reasons. Inmate Epstein has various risk factors for suicidality at thi • ing a high profile case with media attention, sex offense/trafficking charges, pre-trial status, and he had a court o ing yesterday which could have given him bad news regarding his legal situation. As such, this writer instruc &D staff s well as the Lieutenant's Office, to immediately notify the psychology department when he returned fro Inmate Epstein returned from court after duty hours and denied suicidality. The aforementioned staff notifi -call psychologist and inmate Epstein was placed on a precautionary psychological observation status until psychot o rterview him this morning to conduct a suicide risk assessment. Developmental History Inmate Epstein denied any history of being the victim . n. . - .etrator of physical or sexual abuse. Educational History/Cognitive Impairment Inmate Epstein reported he obtained his high school diplom- d some graduate classes in the area of mathematics. Arrest History and Experience of Incarceration Inmate Epstein reported he has served time in Palm Beach County jail se charges (soliciting prostitution) in the past. He is now being charged with sex trafficking, on a federal level. Mental Health History CO Inmate Epstein denied any history of mental health treatment, either on an inpat tient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also d i acute mental health symptoms at this time. Self-Harm History Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever ging in any suicide attempts or self-injurious behavior in the past. Substance Abuse History Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol. Medical Concerns Inmate Epstein denied any significant medical problems, other than a history of high triglycerides. He reported feeling constipated at this time. Current Problem Inmate Epstein is currently on psychological observation due to his having multiple risk factors associated with suicidality. He denies any suicidality at this time and has no mental health or suicide history. He is being seen for a suicide risk assessment in an abundance of caution. Current Mental Status Level of Consciousness: Alert and Oriented SDNY 00017480 Generated 07/09/2019 10:36 by PhD/Chief Bureau of Prisons - NYM — Page 1 of 3 EFTA00139117 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M F ili : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Inmate Epstein did not exhibit any acute psychopathology and exhibited a clear mental status. Current Mental Status: Mr. EP a neutral affect with appropri and volume. His thoughts irrelevant content. There not engage in any bizarre or Ma explicitly denied recent and curre commitment to life and safety, agree' IN was alert and oriented. He was polite, calm, and cooperative in demeanor. He exhibited e. Eye contact and hygiene were appropriate. The inmate spoke with normal rate, tone, nized and coherent, with no loosening of associations or tangential, circumstantial, or ce of perceptual disturbance, delusional ideation, or a formal thought disorder. He did e behavior. He noted having normal sleeping and eating habits. Mr. EPSTEIN eation, planning, and intent. He was future-oriented and expressed a tact staff immediately should he experience suicidal ideation. This writer screened the inmate for a variety of suicide. The following STATIC risk factors were assessed t behaviors: High Profile Crime, Lack of family connect' Of the DYNAMIC risk factors assessed, none were foun validated factors commonly associated with risk for self-harm and and increase the inmate's risk for engaging in suicide related ender status F3 nt. The following PROTECTIVE factors were assessed to be pres m y decrease the inmate's risk of suicide:Able to identify reasons to live, Adequate problem solving skills, Denial of suici ention/plans, Future orientation, View of death as negative, Willingness to engage in treatment As noted above, Inmate Epstein is a 66-year-old Caucasian male. He tV k factors for suicidality at this time including a high profile case with extensive media attention, sex offense/tr c rges, pre-trial status, and he had a court proceeding yesterday which may have given him bad news regarding his leg i Inmate Epstein also informed this writer that his only family at this time is his brother, with whom he does not hav cl tionship with. Despite these risk factors, inmate Epstein possesses a number of protective factors a Inmate Epstein adamantly denied any suicidal ideation, intention or plan. He was very future oriented and requeste all, to meet with his attorney, to take a shower, and to brush his teeth. He was eating his cereal when this writ r d said "I have my paper spoon here." He reported he is going to have a bail hearing on Monday and believes he is go g t sed from jail. Inmate Epstein reported he is a Banker and has a "big business" in the community and that "bei fun." He also revealed he enjoys learning and teaching. He has confidence in his attorney and described him as mpetent." Inmate Epstein denied any mental health history or history of suicidality. He also reported none of his family members have mental health histories. Inmate Epstein stated he is a mathematician and took post graduate classes in this area of study. Inmate Epstein stated he has a support system in the community, including friends and other associates. Finally, inmate Epstein demonstrated a good sense of humor and did not appear dysphoric, agitated or anxious. No acute psychopathology was noted. Overall, inmate Epstein has numerous protective factors at this time that outweigh his risk factors for suicidality. He has a positive outlook regarding his legal case, demonstrates no psychiatric symptoms, has no psychiatric or suicide history, and verbalized a desire to be alive at this time and future orientation. DIAGNOSIS* No Diagnosis, No Dx - Current CONCLUSIONS The Overall Acute Suicide Risk for this Inmate is: Low Overall Chronic Suicide Risk for this Inmate is: Absent Generated 07/09/2019 10:36 by PhD/Chief Bureau of Prisons - NYM SDNY 00017481 - Page 2 of 3 EFTA00139118 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist RECOMMENDATIONS Inmate Epstein is currently on psychological observation pending suitable housing placement. In light of his current sex offense charges and extensive media coverage on the television, he will need to be confined in a suitable housing unit. Inmate Epstein will be seen daily while on psychological observation and will be seen for a psychological observation follow-up session once he is released from observation. Inmate Epstein denied the need for psychological intervention, self-help materials, or follow-up. He has been classified as a CC1-MH inmate at this time. CARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention. Suicide Watch: A suicide watch is not warranted at this time Completed by PhD/Chief Psychologist on 07/09/2019 10:36 060 60, 03/4 oet SDNY 00017482 Generated 07/09'2019 10:36 by Phathiel Bureau of Prisons - NYM - Page 3 of 3 EFTA00139119 Bureau of Prisons Psychology Services Suicide Risk Assessment "SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist Type of Housing: Other Psychological Observation Cell Accommodation: Single Cell FINDINGS This assessment and the resulting recommendations are based on the following sources of information: Clinical Interview, Medical Record Inmate Epstein was placed on chological observation when he returned from court yesterday evening 7/8/19 for precautionary reasons. He i a suicide watch at this time. Reason for Referral Inmate Epstein is being seen f e risk assessment today for precautionary reasons. Inmate Epstein has various risk factors for suicidality at thi • ing a high profile case with media attention, sex offense/trafficking charges, pre-trial status, and he had a court o ing yesterday which could have given him bad news regarding his legal situation. As such, this writer instruc &D staff s well as the Lieutenant's Office, to immediately notify the psychology department when he returned fro Inmate Epstein returned from court after duty hours and denied suicidality. The aforementioned staff notifi -call psychologist and inmate Epstein was placed on a precautionary psychological observation status until psycho terview him this morning to conduct a suicide risk assessment. Developmental History Inmate Epstein denied any history of being the victim . . . - .etrator of physical or sexual abuse. Educational History/Cognitive Impairment Inmate Epstein reported he obtained his high school diplom- d some graduate classes in the area of mathematics. Arrest History and Experience of Incarceration Inmate Epstein reported he has served time in Palm Beach County jail se charges (soliciting prostitution) in the past. He is now being charged with sex trafficking, on a federal level. Mental Health History t Inmate Epstein denied any history of mental health treatment, either on an inpat tient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also d i Stacute mental health symptoms at this time. Self-Harm History Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever ging in any suicide attempts or self-injurious behavior in the past. Substance Abuse History Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol. Medical Concerns Inmate Epstein denied any significant medical problems, other than a history of high triglycerides. He reported feeling constipated at this time. Current Problem Inmate Epstein is currently on psychological observation due to his having multiple risk factors associated with suicidality. He denies any suicidality at this time and has no mental health or suicide history. He is being seen for a suicide risk assessment in an abundance of caution. Current Mental Status Level of Consciousness: Alert and Oriented SDNY 00017483 Generated 07/09/2019 10:36 by PhD/Chiel Bureau of Prisons - NYM - Page 1 of 3 EFTA00139120 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M F ili : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Inmate Epstein did not exhibit any acute psychopathology and exhibited a clear mental status. Current Mental Status: Mr. EP a neutral affect with appropri and volume. His thoughts irrelevant content. There not engage in any bizarre or Ma explicitly denied recent and curre commitment to life and safety, agree' IN was alert and oriented. He was polite, calm, and cooperative in demeanor. He exhibited e. Eye contact and hygiene were appropriate. The inmate spoke with normal rate, tone, nized and coherent, with no loosening of associations or tangential, circumstantial, or ce of perceptual disturbance, delusional ideation, or a formal thought disorder. He did e behavior. He noted having normal sleeping and eating habits. Mr. EPSTEIN eation, planning, and intent. He was future-oriented and expressed a act staff immediately should he experience suicidal ideation. RISK AND PROTECTIVE FACTORS SSED• This writer screened the inmate for a variety of suicide. The following STATIC risk factors were assessed t behaviors: High Profile Crime, Lack of family connect' Of the DYNAMIC risk factors assessed, none were foun validated factors commonly associated with risk for self-harm and and increase the inmate's risk for engaging in suicide related ender status st. The following PROTECTIVE factors were assessed to be pres m y decrease the inmate's risk of suicide:Able to identify reasons to live, Adequate problem solving skills, Denial of suici ention/plans, Future orientation, View of death as negative, Willingness to engage in treatment As noted above, Inmate Epstein is a 66-year-old Caucasian male. He tVr k factors for suicidality at this time including a high profile case with extensive media attention, sex offense/tr c rges, pre-trial status, and he had a court proceeding yesterday which may have given him bad news regarding his leg i Inmate Epstein also informed this writer that his only family at this time is his brother, with whom he does not hav cl tionship with. Despite these risk factors, inmate Epstein possesses a number of protective factors a Inmate Epstein adamantly denied any suicidal ideation, intention or plan. He was very future oriented and requeste all, to meet with his attorney, to take a shower, and to brush his teeth. He was eating his cereal when this writ r d said "I have my paper spoon here." He reported he is going to have a bail hearing on Monday and believes he is go g t sed from jail. Inmate Epstein reported he is a Banker and has a "big business" in the community and that "bei fun." He also revealed he enjoys learning and teaching. He has confidence in his attorney and described him as mpetent." Inmate Epstein denied any mental health history or history of suicidality. He also reported none of his family members have mental health histories. Inmate Epstein stated he is a mathematician and took post graduate classes in this area of study. Inmate Epstein stated he has a support system in the community, including friends and other associates. Finally, inmate Epstein demonstrated a good sense of humor and did not appear dysphoric, agitated or anxious. No acute psychopathology was noted. Overall, inmate Epstein has numerous protective factors at this time that outweigh his risk factors for suicidality. He has a positive outlook regarding his legal case, demonstrates no psychiatric symptoms, has no psychiatric or suicide history, and verbalized a desire to be alive at this time and future orientation. DIAGNOSIS* No Diagnosis, No Dx - Current CONCLUSIONS The Overall Acute Suicide Risk for this Inmate is: Low Overall Chronic Suicide Risk for this Inmate is: Absent Generated 07/09/2019 10:36 by SDNY 00017484 PhD/Chief Bureau of Prisons - NYM — Page 2 of 3 EFTA00139121 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist RECOMMENDATIONS Inmate Epstein is currently on psychological observation pending suitable housing placement. In light of his current sex offense charges and extensive media coverage on the television, he will need to be confined in a suitable housing unit. Inmate Epstein will be seen daily while on psychological observation and will be seen for a psychological observation follow-up session once he is released from observation. Inmate Epstein denied the need for psychological intervention, self-help materials, or follow-up. He has been classified as a CC1-MH inmate at this time. CARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention. Suicide Watch: A suicide watch is not warranted at this time Completed by PhD/Chief Psychologist on 07/09/2019 10:36 060 05 1 ) )6) Generated 07/09/2019 10:36 by PhD/Chief Bureau of Prisons - NYM SDNY 00017485 - Page 3 of 3 EFTA00139122 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/09/2019 08:41 Facility: NYM Amendment made to this note by PhD/Chief Psychologist on 07/10/2019 09:20. Bureau of Prisons SON11000174436 EFTA00139123 Bureau of Prisons Psychology Services General Administrative Note "SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/08/2019 10:41 Provider: PhD/Chief Reg #: 76318-054 Unit Team: A&O Comments This writer consulted with Dr. , Central Office, regarding inmate Epstein. Inmate Epstein has various risk factors for suicidality including a high profile case with media attention, sex offense charges, pre-trial status, and a court proceeding today which could potentially be giving him bad news regarding his legal situation. As such, when inmate Epstein returns from court, R&D staff as well as Lieutenant's have been informed to immediately notify the psychology department. If he returns after duty hours, the aforementioned staff were instructed to notify the on-call psychologist and to place inmate Epstein on a watch status until psychology can conduct a thorough suicide risk assessment. Completed by PhD/Chief Psychologist on 07/08/2019 10:49 Generated 07/08/2019 10:49 by PhD/Chief Bureau of Prisons - NYM SDNY_00017487 Fage 1 of 1 EFTA00139124 Bureau of Prisons Psychology Services Risk of Sexual Abusiveness "SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Date: 07/08/2019 09:35 Provider: PsyD/PhD Reg #: 76318-054 Unit Team: A&O Comments Risk of Sexual Abusiveness During the intake screening process, for Inmate Epstein, based on the documentation available at the time of the screening, and Inmate Epstein's self-report, he was identified as being at risk for sexual abusiveness due to previous perpetration of sexual abuse in the community or in an institutional setting, as evidenced by the following objective criteria: ( ) Having a history of prior institutional violence or sexual abuse perpetration (X ) Having a history of prior sexual abuse perpetration in the community (X ) Having prior convictions of violent offenses As required by P5324.11, Sexually Abusive Behavior Prevention and Intervention, Inmate Epstein was seen by Psychology on today's date to assess his risk factors for sexual abusiveness. At the onset of this clinical contact, the inmate was informed about the BOP requirements regarding PREA. Inmate Epstein indicated he understands the institution's policy against engaging in sexual behavior. His risk factors for sexual abusiveness were assessed and include: ( ) History of prior sexual victimization in prison ( X ) History of prior prison sexual predation ( ) History of head injury with loss of consciousness ( ) History of childhood psychological, physical, sexual abuse ( ) Witnessed family violence ( ) Antisocial Personality Disorder traits of irritability/aggressiveness and recklessness ( ) Hypersexuality (defined by eight or more orgasms a week prior to prison) ( ) Hypermasculinity ( ) Other: Based on this clinical assessment, the inmate is considered to be at: (X ) Low Risk of Abusiveness at this facility (Note: Even though this inmate is judged to be at low risk of sexual abusiveness, an unforeseen change in risk factors may significantly alter his risk level.). Programming recommendations included sex offender treatment. Inmate Epstein declined programming recommendations.The inmate understands the procedure for contacting Psychology for routine or emergent services. ( ) Moderate Risk of Abusiveness. The Unit Team and Correctional Staff have been notified regarding Psychology staff's recommendation that he not be housed in a cell with any inmates identified as at increased risk for sexual victimization. Psychology also recommends a greater level of supervision regarding his work and education assignments. Programming recommendations include XXXXX. Inmate =inmateLastName is agreeable to/ declined programming recommendations. ( ) High Risk of Abusiveness. It is recommended this inmate be housed in the Special Housing Unit in accordance with P5324.11 to "keep separate those inmates at high risk of being sexually victimized from those at high risk of being sexually abusive" until Correctional Services and Correctional Programs staff can assess his appropriateness for general population at this facility. This inmate should not be housed with any inmates judged to be at an increased risk for sexual victimization. Programming recommendations include XXXXX. Inmate =inmateLastName is agreeable to/ declined programming recommendations. Generated 07/08/2019 09:41 by PsyDrPhD Bureau of Prisons - NYM SDNY_0001708 rage 1 of 2 EFTA00139125 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M F ility: NYM Date: 07/08/2019 09:35 Provider: PsyD/PhD Reg #: 76318-054 Unit Team: A&O Completed by PsyD/PhD on 07/08/2019 09:41 SDNY_00017489 Generated 07/08/2019 09:41 by PsyD1PhD Bureau of Prisons - NYM Page 2 of 2 EFTA00139126 Bureau of Prisons Psychology Services Intake Screening "SENSITIVE BUT UNCLASSIFIED" Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A&O Date: 07/08/2019 09:24 Provider: . PsyD/PhD Limits of Confidentiality Limits of confidentiality were reviewed with inmate EPSTEIN. He expressed an understanding of the limits of confidentiality and consented to be interviewed accordingly. Data Source(s) The following data sources were reviewed in conjunction with this Initial Intake Evaluation: Self-Report, SENTRY, Staff Observation. Inmate Epstein is a 66-year-old, Black male who was seen by Psychology Services due to newly arriving at MCC-NY. He denied a history of mental health treatment on his Psychology Services Intake Questionnaire. Mental Health History and Current Symptoms No history of mental health issues was noted. No history of prior mental health treatment was noted. No current mental health symptoms were noted. No suicidal ideation, attempts, or self-harm were noted. Substance Abuse No history of substance abuse was noted. No history of substance abuse treatment was noted. Sex Offenses No sexual offense convictions were noted. No history of sexual predation in a correctional setting was noted. Relevant Psychosocial History Noteworthy psychosocial issues: Other. Inmate Epstein is currently incarcerated for a Sex Trafficking. He stated he was previously incarcerated three months f or prostitution. Inmate Epstein stated he is single and does not have any children. He revealed he was living in New York. He stated he completed high school. He stated he was employed in banking work prior to his incarceration. Adjustment to Incarceration Adjustment to incarceration concerns were identified: Other. SEXUAL ABUSE HISTORY Inmate Epstein denied being the victim of physical or sexual abuse. He is currently charged with sex trafficking and has previously been charged with prostitution. He was informed of the programs offered by MCC-NY as well as the Bureau of Prisons. Additionally, he was informed of this institutions self-help program. Inmate Epstein reported he was not currently interested in any treatment programs. MENTAL STATUS: Inmate Epstein appeared calm, controlled, without signs of psychomotor agitation or retardation. He was fully cooperative, maintained good eye-contact, and related in an interpersonally appropriate manner with interviewer. Speech and thought processes were organized, coherent, logical, and goal-directed. Based on informal assessment during this interview, this inmate's cognitive functioning appeared within normal limits, as reflected by adequate long and short-term memory, good attention, and appropriate concentration during interview, as well as adequate receptive and expressive language skills. Inmate denied any current sleep disturbances and described his appetite as adequate. This inmate denied recent or present morbid thoughts, passive or active suicidal ideation, intent or plan and contracted for safety. This inmate's verbalizations were optimistic, future oriented, and without indications of helpless or hopeless thinking. Inmate Brown denied any familial history of suicide behaviors or attempts. This inmate was provided with supportive psychotherapy, and psycho-education to strengthen coping skills and facilitate adjustment to incarceration. Findings Care Level: CARE1-MH SDNY_00017490 Generated 07/08/2019 09:30 by PsyD/PhD Bureau of Prisons - NYM Page 1 of 2 EFTA00139127 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M F tli : NYM Date: 07/08/2019 09:24 Provider: PsyD/PhD Reg #: 76318-054 Unit Team: A&O Inmate EPSTEIN denied any history of mental health symptoms or treatment. He denied any current mental health symptoms. He does not meet criteria for any current psychological diagnosis. He meets criteria for Mental Health Care Code 1. CARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention. Recommendations The following psychological services are recommended: Other. Inmate EPSTEIN was educated about both routine and emergency procedures for contacting Psychology staff. He does not appear to be in distress at this time. He agreed to contact psychology if he feels he needs psychology services in the future. He meets criteria for CC1 and does not require scheduled follow up at this time. Completed by . PsyD/PhD on 07/08/2019 09:30 Generated 07/08/2019 09:30 by PsyD/PhD Bureau of Prisons - NYM SDNY_00017491 Page 2 of 2 EFTA00139128 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 Collected 07/09/2019 13:34 Order Unit E06-547U Received 07/10/2019 10:44 Provider MD Reported 07/10/2019 14:46 LIS ID 188191004 CHEMISTRY Sodium Potassium Chloride CO2 BUN Creatinine eGFR (IDMS) 137 4.7 99 27 17 1.05 >60 137-148 3.5.5.0 99.114 22-30 7-22 0.66.1.25 mmol/L mmol/L mmol/L mmol/L mg/dL mg/dL GFR units measured as mUmin/1.73 m^2. If African American multiply by 1.210. A calculated GFR <60 suggests chronic kidney disease if found over a 3 month period. Calcium 9.8 8.5-10.9 mg/dL Glucose 102 70-110 mg/dL AST H 57 11.55 U/L ALT 62 11-66 U/L Alkaline Phosphatase 64 41.133 U/L Bilirubin, Total 1.1 0.2.1.3 mg/dL Total Protein 7.3 6.0-8.2 g/dL Albumin 4.4 3.6.5.1 g/dL Globulin 2.9 2.0.3.7 g/dL Alb/Glob Ratio 1.50 1.00-2.30 Anion Gap 10.2 9.0.19.0 BUN/Great Ratio 16.1 5.0.30.0 Cholesterol H 216 <200 mg/dL Triglycerides H 413 10-150 mg/dL Calculation of LDL is not appropriate for samples with a triglyceride greater than 400 mg/dL. Therefore the LDL is not calculated. HDL Cholesterol L 31 40.60 mg/dL Chol/HDL Ratio H 6.9 0.0.4.0 WBC 7.6 4.3-11.1 K/uL NRBC% 0.0 RBC 5.42 4.46-5.78 M/uL Hemoglobin 15.6 13.6-17.6 g/dL Hematocrit 47.8 40.2-51.4 MCV 88.2 82.5-96.5 fL MCH 28.8 27.1-34.9 Pg MCHC L 32.6 33.0-37.0 g/dL ROW-CV 12.8 12.0-14.0 Platelet 338 130-374 K/uL FLAG LEGEND L=Low L!=Low Critical H=High H!=High Critical A=Abnormal A! =Abnormal Critical Page 1 of 3 SON\100017492 EFTA00139129 Federal Bureau of Prisons U.S. Medical Center for Federal Prisons 1900 W. Sunshine Street Springfield, MO 65807 417-874-1621 'es Sensitive But Unclassified *** Name EPSTEIN, JEFFREY Reg # 76318-054 DOB 01/20/1953 Sex M Facility MCC New York Order Unit E06-547U Provider Collected 07/09/2019 13:34 Received 07/10/2019 10:44 MD Reported 07/10/2019 14:46 LIS ID 188191004 HEMATOLOGY MPV 10.4 6.9-10.5 fL Neutrophils % 58.7 Therapeutic decision making should be based on absolute values, rather than percentages Lymphocytes % 25.0 Monocytes % 11.1 Eosinophils % 4.1 Basophils 0.8 Immature Granulocytes % 0.3 0.0-5.0 6/0 Neutrophils # 4.4 1.9.6.7 MIL Lymphocytes # 1.9 1.3.3.7 KJuL Monocytes # 0.8 0.3-1.1 K/uL Eosinophils # 0.3 0.0.0.5 K/uL Basophils # 0.1 0.0.0.1 K/uL Immature Granulocytes # 0.02 0.00-0.50 10^3/uL HEMOGLOBIN A1C Hemoglobin A1C H 6.3 <5.7 5.7 - 6.4 Increased Risk > 6.4 Diabetes SEROLOGY RPR Non-Reactive Non-Reactive Results may be affected in patients with severely advanced immunosuppression. FLAG LEGEND L=Low L!=Low Critical H=High H!=High Critical A=Abnormal A! =Abnormal Critical Page 2 of 3 SDNY_00017493 EFTA00139130 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 • See confirmatory testing for Reactive results Negative FLAG LEGEND L=Low L!=Low Critical H=High Fn.-High Critical A=Abnormal A! =Abnormal Critical Page 3 of 3 SDNY_00017494 EFTA00139131 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/10/2019 16:58 Provider: Lab Result Receive Facility: NYM Cosigned by MD on 07/14/2019 18:12. Bureau of Prisons - NYM SDNV_00017495 EFTA00139132 , BP.A0489 JUN 10 HIV COUNSELING DOCUMENTATION • U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Directions: Use the folloWing criteria to counsel the patient who Is tested for the HIV anibody. Che• ck off each item as they are discussed. Write NA beside any item that is inappropriate to the situation. Thercverse side of this form will be utilized to .docuritent seronegative and inconclusive test result. Then file to the patient's record, documenting in progreis notes that counseling was completed. PRETEST: ▪ 1, Explain purpose of session. 2. Explain:contidentiality.. ▪ 3. Explain HIV antibody test. a. What HIV is b. What the test is Test Procedure Meaning of test results _~__e. Inability of detecting early infection (false negatives) f. Potential need for additional testing Significance of a positive test. Ust risk factors/clinical signs: (check all that apply) a. Injecting drug use, sharing drug or tattoo equipment b. Unprotected or multiple sex partners No. Treated for sexually transmitted Infections, hepatitis, or TB : Pregnant female Other. Clinical sus: fever or illness of unknown cause, symptoms of AIDS opportunistic infecfions. Exposure: recent occupational or non-occupational exposafincident, ..e. Obtain Informed consent (when applicable). . Risk Reduction Behaviors. Educational material given. /7, Patient Reactions/Comments. Explain how the patient will be notified of the result. The above information has been explained to me in a language 1 can understand. Signaline of Inmate r SDNY_00017 Replacts [3P-5489.061 of APR rile in Ilhisdyledical Record: Section 6. Prescribed by P6190 EFTA00139133 BP-S355.060 SEP 05 r MEDICAL TREATMENT R FUSAL CDFRM U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-9-2019 Date 1, 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: Rectal and genital examination The following treatments) waslwere recommended: Rectal and genital examination 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: Undetected and untreated medical condition. I understand the possible consequences and/or complications listed above, and still refuse recommended treatment. f hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and allnability for respecting and following my expressed wishes and directions. MLP Counseled by a.-.) nicc • MCC NY -9-2019 Date t 1/4 5 Signature of Witness L Date Date Patient's Signa NYM-NEW YORK MCC SDNY_00017497 EFTA00139134 BP-S358.060 MEDICAL TREATMENT REFUSAL CDFRM SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and Its employees from any and all liability for respecting and following my expressed wishes and directions. MD 7-24-2019 Counseled by Date c7a,r =M i n NYM-NEW YORK MCC SDNY_00017498 EFTA00139135 BP A0516 JUN 16 U.S. DEPARTMENT OF JUSTICE A&O DENTAL EXAMINATION (Initial Clinical Dental Findings) FEDERAL. BUREAU OF PRISONS Occlusion: 1 2 1 4 5 0 7 8 0 10 11 12 13 14 15 10 m EE C 9 32 31 10 29 28 27 26 25 24 23 22 21 20 19 18 17 (54 (AL Oat 411 Oral Hygiene: CPITN: Good Farr Poor 2 2- Head & Neck i Soft Tissue: 3 M: I Classification: CL Pain Sea /10 Dental Prostheses at Intake: Yes No Type: Age: Condition: Cardiff" 4O ced Cardiff r-cuss, on 01;) 14."Xe-r O..,.-motor an Senite-j \Ai . gy,15, • Cet-OliA c Ok SCAte4 Infra-oral Photos Taken: Yes 0 Radiographs Taken: (Document findipgs on A&O encounter) Yes 9 Instructed how to obtain urgent and non-urgent dental care: Yes: If No: Treatment Priorities: None: Non-urgent: non-urgent Urgent Referred to Sick Call: Radiographs authorized: PAs: Prophylaxis authorized: Yes I No (Approval valid 18 months from examination date) Ef/Vs: Panoror P n1 Name: S n -3 —e5-2 32_ E Dentist Signature: I>DS gist -7c, Number: 3 i cc: Ocy Institution: MCC NEW YORK Date: 7. - 2 4 1 -1 9. Signature Block/Stamp: DDS. PDF Prescribed by P6400 ief Dental cer MCC New York Replaces BP-A0018 of JUN 10 SONY_00017499 EFTA00139136 Counseled by Date BP-S358 06O 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) waslwere recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. Pa is Sit NYM--NEW YORK MCC Date SDNY_0001 7500 EFTA00139137 BP-5353.0€0 Sit, C5 MEDICAL TREATMENT REFUSAL CDFRM 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 conditionfs): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: 66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR. The following treatment(s) was/were recommended: CHEST X-RAY Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: WORSENING THE CONDITION IF THERE IS ANY FINDINGS I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. X-RAY 7-10-2019 Counseled by Date Patient Signature (Cc Signature of Witness Date NYM-NEW YORK MCC Date SDNY_00017501 EFTA00139138