EFTA00035180

BP-S358.060 SEP 05 MEDICAL TREATMENT REFUSAL CDFRM U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that 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. 7-24-2019 Counseled by Date NYM-NEW YORK MCC EFTA00035180 BP-S358C80 MEDICAL TREATMENT REFUSAL CDFRM SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-10-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: 66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR. The following treatment(s) was/were recommended: CHEST X-RAY Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: WORSENING THE CONDITION IF THERE IS ANY FINDINGS I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. X-RAY 7-10-2019 Counseled by Date Patien Signature Date Date ( q, NYM-NEW YORK MCC EFTA00035181 BP-5358.060 MEDICAL TREATMENT REFUSAL CDFRM SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date JEFFREY EPSTEIN 76318-054 refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. 4 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. 7-24-2019 Counseled by Dale Pa nt's Si Date NYM--NEW YORK MCC EFTA00035182 BP-A0618 A&O DENTAL EXAMINATION JUN 15 (Initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Occlusion: Oral Hygiene: Good Fair , oar • AA 1 2 1 4 5 6 7 8 9 1011 1213 14 15 18 rg CP:TN: Head 8 Neck / Soft Tissue: 3 3 2- 3 3 O CC 32 31 30 2D 28 27 2825 24 23 22 21 20 19 • 18 17 21 Classification: mmomel;;' D: M: I CL F: I Li Pain Scale: /10 Dental Prostheses at Intake: ComnAl Ii7 aC r: Ft , riV )72.5 i Vet" Yes Type: Age: No r-ccess.cy-) ekt Sen) -e- L.7 -se-e- C—Niell Or Cat.SajA c 0.1050-M 4 Condition: Intra-oral Photos Taken: Radiographs Taken: (Document findings on A8O encounter) Yes Yes 0 9 • Instructed how to obtain urgent and non-urgent dental care: Yes: 1 No: Treatment Priorities: None: Non-urgent Urgent Referred to Sick Cali: non-urgent Radiographs authorized: Prophylaxis authorize& Yes i No PM: (Approval valid 18 months from examination date) BWs: Panoreic irnt Name: i skin,t -0 -4 -li --e_v S kmf -Number. --7(, 3 lc= Us-Li MCC institution: / NEW YORK Date: 7- 26 -/ 9. l>DS Signature Biock/Stamp: 'DS. het uentalOfficer MCC New York PDF Prescribed by P6400 Replaces BP-A0618 of JUN 10 EFTA00035183 BP-A0618 A&O DENTAL EXAMINATION JUN 18 (initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Oodusion: Oral Hygiene: Good Fair Poor 3 2- 3 3 2- Head & Neck / Soft Tissue: I 1 2 3 4 5 0 7 8 0 1011 1213 14 15 16 rm - 0 32 31 30 2D 28 27 26 25 24 23 22 21 20 10 18 17 Classification: D fa CL_ F: Pain Scale: /10. Dental Prostheses at Intake: Cot _to zt= Yes No rii ..g),:i ilitca Type: R Ce SS / OO DICX Sen.) -e-a Age: 14,0 4- 1 0-4c1 pc Condition: caolim 0.10scAle4 Intra-oral Photos Taken: . Radiographs Taken: (Document findings on A&O encounter) Yes yes 0 O • Instructed how to obtain urgent and non-urgent dental care: Yes: I No: Treatrnent Priorities: None: Non-urgent Urgent Referred to Sick can: non-urgent Radiographs authorized: - Prophylaxis 811 k Yes V No PM: (Approval read 18 months flan examination date) BWs: Panorer Patient Name: Dent' ' ft, E bps r Number: n' -3-e_Institution: c-rity/ Date: • Stamp: 76 3 I S r- OS-LI MCC NEW YORK 7- 2-6 -I 9. DS. let L)ental Umcer MCC New York PDF Prescribed by P64C0 Replaces BP-A0618 of JUN 10 EFTA00035184 OP-S358.060 MEDICAL TREATMENT REFUSAL COFRM 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. 7-24-2019 Dale S Date NYM-NEW YORK MCC EFTA00035185 Federal U.S. Medical Center for Federal Prisons Bureau of 1900 W. Sunshine Street Prisons Springfield, MO 65807 417-874-1621 "' Sensitive But Unclassified "" Name EPSTEIN, JEFFREY Facility MCC New York Collected 07/09/2019 13:34 Reg # 76318-054 Order Unlit Received 07/10/2019 10:44 DOB 01/20/1953 Provider MD Reported 07/10/201914:46 Sex M LIS ID 188191004 HIV HIV 1/2 Negative Negative Screening test - See confirmatory testing for Reactive results FLAG LEGEND L=Low L!=Low Critical H=High H!=High Critical A=Abnormal A! =Abnormal Critical Page 3 of 3 EFTA00035186 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/10/2019 16:58 Provider: Lab Result Receive Facility: NYM Cosigned by on 07/14/2019 18:12. Bureau of Prisons - NYM EFTA00035187 BP-S358.060 MEDICAL TREATMENT REFUSAL CDFRM SEP 05 F 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 ex ressed wishes and directions. 7-24-2019 Date Pa is Sign Date NYM-NEW YORK MCC . 427 Date fi EFTA00035188 BP-A0618 A&O DENTAL EXAMINATION JUN 16 (Initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Occlusion: Oral Hygiene: Good Fair Poor ip;IN4 3 4 5 6 7 8 0 1011 1213 14 15 16 i; CPITN: 3 Head & Neck r Soft Tissue: 3 2- 3 10 20 28 27 2825 2423 22 21 20 10 18 17 Classification: ccGa C CL F: / L i Pain Scale: /10 ri !!! i Ng t Dental Prostheses at Intake: Connont iv Citil Q PI )75iva Yes Type: Age: No RQss, on Ck;Seit)-e- 1.0.„)4- „ 4 C,--.....\ciet eV' Condition: Cong. in i Cklo WA' Intra-oral Photos Taken: Radiographs Taken: (Document findings on A8O encounter) Yes Yes 0 9 Instructed how to obtain urgent and non-urgent dental care: Yes: / No: Treatment Priorities: None: Non-urgent Urgent Referred to Sick Call: non-urgent Radiographs authorized: Prophykoes authorized: Yes i No PM: (Approval valid 18 months from examination date) BWs: Panama Pert Name: i . Dent:slim ! W s4c4 n iistfiNumber. , -) c_c-ri-tv E I bps Institution: / Date: Ignature Block/Stamp: -7G 3 ag; as-1/41 MCC NEW YORK 7- z6, -/ 9. DDS. let venial ccer MCC New York PCP Prescribed by PSICO Replaces BP-A0618 of JUN 10 EFTA00035189 SP-S358.060 MEDICAL TREATMENT REFUSAL COFRM 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 treatments) 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. 7-24-2019 Date Pa is Sig Date t19 NYM-NEW YORK MCC Date EFTA00035190 BP-S358.060 MEDICAL TREATMENT REFUSAL CDFRM SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-10-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: 66 YR OLD MALE WITH NO PIVIHX , 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 tho 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 Date ES±li Date cr NYM-NEW YORK MCC EFTA00035191 0P-A0618 A&O DENTAL EXAMINATION JUN 16 (Initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Occlusion: Fair Poor • NM Oral Hygiene: Good CPITN: 3 z 3 2- 9 Head & Neck! Soft Tissue: S 1 2 3 4 5 6 7 8 9 1011 1213 14 15 16 WI L9 32 31 30 20 28 27 2625 2423 22 21 20 10 18 17 Classification: D: M: CL? F: Pain Sonic: /1G Dental Prostheses at Intake: Comirai 42 120.- Yes No tql 173 I IAa Type: it (12 SSi on Di,Seru-e. • Age: Let....5er 0....N. skol or Congini 0.105/CAW Condition: Intra-cral Photos Taken: Radiographs Taken: (Document findings on A&O encounter) Yes Yes 0 9 • Instructed how to obtain urgent and non-urgent dental care: Yes: I No: Treatment Priorities: None: Non-urgent Urgent Referred to Sick Cal. non-urgent Radiographs authorized: • Prophylaxis authorized: Yes I No PM: (Approval va5d 18 months from examination date) Ms: Panormc Pent Name: I Dent; 54Q n , --)c.0Tizy E IIIII.Lbr)s 4 Number --n, 3 IQ: ()Sy mcc / Institution: / NEW YORK Date: 7- 0-0 -1 9. ignature Block/Stamp: DDS. Chief Dental Officer MCC New York PDF Prescribed by P6400 Replaces BP-A0618 of JUN 10 EFTA00035192 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: 08/1012019 07:25 Provider: RN Unit: Z04 Emergency Code - Resuscitation Event encounter performed at Special Housing Unit. SUBJECTIVE: Emergency Note Provider: RN Team Members: Provider Ha& RN Team/Code Leader Code Events: Tvoe Value Date CPR Compressions 08/10/2019 06:35 EKG/Monitor Lifepak 08/10/201906:39 No shock advised CPR Compressions 08/10/2019 06:40 Oxygen 15L 08/10/201906:47 IV Access Peripheral IV 08/10/2019 06:48 18g Left AC Airway Endotracheal Tube 08/10/2019 07:08 ET Tube 7.5 24CM to L Lip line Placed by Paramedics Medications Epinephrine 1mg IV 08/10/201907:10 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 08110/2019 06:10 by RN Bureau of Prisons - NYM Page 1 of 2 EFTA00035193 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 Exam: ASSESSMENT: Cardiac Arrest PLAN: New Consultation Requests: Consultation/Procedure Target Date Scheduled Target Date Priority Translator Ianauage 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 Cosign documentation will be displayed on the following page. Generated 08/10/2019 08:10 by RN Bureau or Prisons • NYM Pats 2 of 2 EFTA00035194 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. Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT WAS REFERRED BY THE WARDEN FOR EVALUATION. PATIENT REPORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO REPORTS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STATES THE NUMBNESS WENT AWAY ON ITS OWN. BUT WAS VERY CONCERNING. HE DENIES RIGHT SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OR SWALLOWING. HE REPORTS NOCTURIA OF ABOUT 5 TIMES.. HE DENIES DYSURIA. HE REPORTS 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 Ginersted 07/30/2019 16:12 by Bureau of Prisons • NYM Pop 1 of 2 EFTA00035195 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. 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: Medication Order Date Prescriber Order INsulin REG - Human 07/30/2019 15:58 SLIDING SCALE Subcutaneously each morning x 7 day(s) Pill Line Only Indication: Prediabetes Discontinued Medication Orders: Bat Medication Order Date Prescriber Order 122148-NYM Insulin Reg (10 ML) 100 UNITS/ML Inj 07/30/2019 15:58 Inject regular insulin subcutaneously per sliding scale: twice daily "pill line"' for 7 days Discontinue Type: When Pharmacy Processes Discontinue Reason:new order written Indication: Copay Required: No Cosign Required: No TelephoneNerbal Order: No Completed by on 07/30/2019 16:12 Generated 07/30/2019 16:12 by Bureau or Prisons • NYM Page 2 of 2 EFTA00035196 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 11:12 Provider: Unit: 201 Chronic Care • Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT S REFERRED BY THE WARDEN FOR EVALUATION. PATIEN RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STAT BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. HE DENI SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OWING. HE REPORT IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. HE REPORTS H NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEP AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN CE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE R HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-ME STATES HE FEELS OTHERWISE Pain: Not Applicable Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology. OBJECTIVE: Pulse: DAM Time Rate Per Minute Location Provider 07/30/2019 13:02 94 eaudouin, Robert MD 07/30/2019 09:40 88 Via Machine ouin, Robert MD 07/30/2019 09:30 87 Via Machine Robed MD Respirations: Date Time Rate Per Minute provider 07/30/2019 09:30 NYM 12 Blood Pressure: =St Time Mks Location Position Cuff Size provider 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: pate lime NtaltLet%1 Air Elnyld_er 07/30/2019 09:30 NYM 98 Room Air Weight: Date Time Was Kg Waist Circum. Gonoralod 07/30201914:05 by &MOM of Prisons NYM Pogo 1 of 3 EFTA00035197 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 11:12 Provider: Unit: 201 Date Time Lim Kg Waist Circum Provider 07/30/2019 09:30 NYM 194.2 88.1 Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distre S. Dyspneic, Appears in Pain, Writhing in Pain. Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unk cutely III Nutrition No: Appears Ob Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR 1 and S2 No: M/R/G Musculoskeletal Tibia / Fibula No: Edema di) Neurologic Cranial Nerves Nor (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0-27.9, adult, 26827 - Current 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: &it accusation Order Date Prescriber Order Generated 07/30/2019 14:05 by Bureau of Prisons • NYM Page 2 of 3 EFTA00035198 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 11:12 Provider: Unit: Z01 New Medication Orders: Rx# Me itc_ation Oider_CiaSe Prescriber Order Magnesium Hydroxide Susp conc 800 07/30/2019 11:12 10 CC Orally - Two Times a MG/5ML Day PRN x 90 day(s) Indication: Constipation, unspecified INsulin REG - Human 07/30/2019 11:12 SLIDING SCALE Subcutaneously - Two Times a Day x 7 day(s) Pill Line Only Indication: Prediabetes Renew Medication Orders: F#c Medication Order Date Prescriber Order 121836-NYM methylPR ne 4 MG Tab ( 21 count 07/30/2019 11:12 Take the tablet by mouth as Pack) directed x 6 day(s) Indication: y= z11 is and neuritis, unspecified New Laboratory Requests: Details Frequency Due Date Priority Lab Tests - Short List-General-CBC w/diff ne Time 08/01/2019 00:00 Routine 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 Ernwency Due Date Priority General Radiology-Spine / Cervical- One Time 08/29/2019 Routine General Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI R 2-3 MINUTES 3 DAYS AGO. PLEASE PERFORM C SPINE SERIES Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format Handout/Topic Outcome 07/30/2019 Counseling Access to Care Verbalizes Understanding 07/30/2019 Counseling Plan of Care Verbalizes Understanding Copay Required:No Cosign Required: No TelophoneNerbal Order: No Completed by on 07/30/2019 14:05 Generated 07/30/2019 14:05 by Bureau or PlISOIIS • NYM Page 3 of 3 EFTA00035199 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 11:12 Provider: Unit: 201 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT S REFERRED BY THE WARDEN FOR EVALUATION. PATIE RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STAT BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. HE DENI SIDED WEAKNESS, DIPLOPIA. FACIAL DROOP, DIFFICULTY SPEAKING OWING. HE REPORT 'VIA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. HE REPORTS H .. a NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEP .;,t•-ti.f..x.t• AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN - - ..-••9i,tCE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE R HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-ME ES. STATES HE FEELS OTHERWISE Pain: Not Applicable Seen for clinic(s): Endocrine/Lipid. Orthopedic/Rheumatology, Respiratory OBJECTIVE: Pulse: Date Time Rate Per Minute lac_atiort 07/30/2019 13:02 94 MD 07/30/2019 09:40 88 Via Machine MD 07/30/2019 09:30 87 Via Machine MD Respirations: Date Time Rate Per Minute Provider 07/30/2019 09:30 NYM 12 Blood Pressure: Date im Value Location Position Cuff Size Provider 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 Sa02: Date Time Value(%) Air Provider 07/30/2019 09:30 NYM 98 Room Air Weight: Dat€ Time L1)..s. Kg Waist Circum Provider Generated 07/30/2019 14:05 by Ehlteall of Prisons • NYM Page 1 of 3 EFTA00035200 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Binh: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: Unit: Z01 Data Time Lila. Ka Walett.Cirons provider 07/30/2019 09:30 NYM 194.2 88.1 Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distre ed, Dyspneic. Appears in Pain, Writhing in Pain, Pale, Pallor. Cyanotic, Diaphoretic, Disheveled, linke cutely III Nutrition No: Appears Obw Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR and S2 No: WR/G Musculoskeletal Tibia I Fibula No: Edema Neurologic Cranial Nerves (CN) 411°) Yes: Within Normal Limits 0 Motor System-General Yes: Normal Exam Motor System-Strength >dir 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: Medication Order Date Prescriber Order Generated 07/30/2019 14:05 by Bureau of Prisons - NYM Page 2 of 3 EFTA00035201 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 11:12 Provider: Unit: Z01 New Medication Orders: Rx# Medication. Order Date Prescriber Order Magnesium Hydroxide Susp conc 800 07/30/2019 11:12 10 CC Orally - Two Times a MG/5ML Day PRN x 90 day(s) Indication: Constipation, unspecified INsulin REG - Human 07/30/2019 11:12 SLIDING SCALE Subcutaneously - Two Times a Day x 7 day(s) Pill Line Only Indication: Prediabetes Renew Medication Orders: fix# Medication Order Date Prescriber Order 121836-NYM methylP ne 4 MG Tab ( 21 count 07/30/2019 11:12 Take the tablet by mouth as Pack) directed x 6 day(s) Indication: is and neuritis, unspecified New Laboratory Requests: Details Frequency Due Date Priority Lab Tests - Short List-General-CBC w diff ro e Time 08/01/2019 00:00 Routine 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 Frequency Due Date Priority General Radiology-Spine / Cervical- One Time 08/29/2019 Routine General Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI R 2-3 MINUTES 3 DAYS AGO. PLEASE PERFORM C SPINE SERIES Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format Handout/Tooic Outcome 07/30/2019 Counseling Access to Care Verbalizes Understanding 07/30/2019 Counseling Plan of Care Verbalizes Understanding Copay Required: No Cosign Required: No TelephoneNerbal Order: No Completed by on 07/30/2019 14:05 Generated 07130/2019 14:05 by Bureau of Prisons NYM Page 3 of 3 EFTA00035202 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 on 07/30/201916:12. Bonsai of Prisons • NYM EFTA00035203