EFTA00059443

Bureau of Prisons Health Services Cosign/Review Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Race: WHITE 01/20/1953 Sex: M Date of Birth: MLP Facility: N M 07/09/ 2019 12:35 Provid er: Encounter Date: Cosigned by MD on 07/11/2019 22:41. Burew W ftilscm - WM EFTA00059443 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 atatua Hyperlipldemia, 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 In lorded. Medications: All medications to be continued until evaluated by a physician unless otherwise Bolded drugs required for transport. ily for 30 days Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take one capsule (100 MG) by mouth twice 01/22/2020 SIG: Take one capsule (100 MG) twice daily by th with plenty Docusate Sodium 100 MG Cap Exp: of water th twice Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML Exp: 10/28/2019 SIG: shake well take 10mI by daily AS NEEDED Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by uth with food OTCs: Listing of all known OTCs this inmate is currently taking. None Pending Appointments lima Activity Provider Dale 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 Frequency Dualism Retails EKG 07/06/2019 One Time 66 y/o male Focal 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: Results: TB Treatment Sx free for 30 days: Yes TB Follow-up Recommended: No Sickle Cell: Sickle Cell Trait/Disease: No RN Bureau of Prisons - NYM Page 1 of 2 Generated 08/10/2019 07:00 by EFTA00059444 Reg 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD d. SENSITIVE BUT UNCLASSIFIED — This Won-nation Is confidential and must be appropriately safeguard Limitations:Restrictions/Diets: Cell: lower bunk — 10/09/2019 Cleared for Food Service: Yes Other diet restrictions: FISH ALLERGIES. — 07/30/2020 Comments: Allergies No Known Allergies Devices / Equipment C-Pap Travel: Direct Travel: No Travel Restrictions: None UNIVERSAL PRECAUTIONS OBSERVED WHEN TRANSPORTING ANY INMATE: Transfer From Institution: NEW YORK MCC Phone Number. 6468366300 Address 1: 150 PARK ROW Address 2: City/State/Zip: NEW YORK, New York 10007 Namerfltle of Person Completing Form: RN Dal 08/10/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 DOB: 01/20/1953 Generated 08110/2019 07:00 by RN Bureau al Prisons - NNW Page 2 of 2 EFTA00059445 Bureau of Prisons Health Services Vitals All Begin Date: 07/07/2019 End Date: 08/10/2019 Rog #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Temperature: Data Tiffin Fahrenheit Celsitot Location Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral .MLP Orig Entered: 07/24/2019 13:14 EST MLP 07/23/2019 06:30 NYM 97.5 36.4 Oral .MLP Orig Entered: 07/23/2019 08:33 EST MLP 07/09/2019 12:49 NYM 97.3 36.3 Oral .MLP Orig Entered: 07/09/2019 12:51 EST MLP Pulse: Time Rate Per Minute I ocation Rhythm Provider 12lita 94 MD 07/30/2019 13:02 Orig Entered: 07/30/2019 13:04 EST MD 88 Via Machine MD 07/30/2019 09:40 Orig Entered: 07/30/2019 13:04 EST MO 87 Via Machine MD 07/30/2019 09:30 Orly Entered: 07/30/2019 12:59 EST MD 81 RN 07/28/2019 20:28 Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 82 Orig Entered: 07/28/2019 06:58 EST RN 83 Via Machine Regular 7! RN 07/24/2019 13:12 Orly Entered: 07/24/2019 13:14 EST . MLP 92 Via Machine Regular .MLP 07/23/2019 06:30 Orig Entered: 07/23/2019 08:33 EST . MLP 82 Via Machine Regular .MLP 07/09/2019 12:49 Orig Entered: 07/09/2019 12:51 EST MLP Respirations: Bata Inn Rate Per Minute Provider 07/30/2019 09:30 NYM 12 MD Orly Entered: 07/30/2019 12:59 EST MD 07/28/2019 20:28 NYM 14 RN Orlg Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 NYM 14 RN Orig Entered: 07/28/2019 06:58 EST RN 07/23/2019 06:30 NYM II WMLP Orly Entered: 07/23/2019 08:33 EST . MLP 07109/2019 12:49 NYM 16 . MLP Orig Entered: 07/09/2019 12:51 EST . MLP Bureau of Prisons - NYM Pogo 1 or 3 Generated O8V10/2019 11:02 by EFTA00059446 Begin Date: 07/07/2019 End Date: 08/10/2019 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: Blood Pressure: Value ) °cation Position Cuff Size provider Date lima Left Arm Standing Beaudouin, Robert MD 07/30/2019 13:02 NYM 114/84 Orig Entered: 07/30/2019 13:04 EST MD Right Arm Standing EMINIMMD 07/30/2019 09:40 NYM 125/60 Orig Entered: 07/30/2019 13:04 EST MO Left Ann Sitting MIMI"( MD 07/30/2019 09:30 NYM 108/86 Orig Entered: 07/30/201912:59 EST MD RN 07/28/2019 20:28 NYM 157/91 -U Orig Entered: 07/28/2019 20:29 EST RN RN 07/28/2019 06:57 NYM 138/80 Orig Entered: 07/28/2019 06:58 EST RN Right Arm Sitting Adult-regular MLP 07/24/2019 13:12 NYM 132/89 Orig Entered: 07/24/2019 13:14 EST MLP 07/23/2019 06:30 NYM 140/85 Right AIM Sitting Adult-regular MLP Orig Entered: 07/23/2019 08:33 EST MLP 07/09/2019 12:49 NYM 117/66 Right Arm Sitting Adult-regular Ma MLP Orig Entered: 07/09/2019 12:51 EST MLP Blood Glucose: Thus Time Value imgldll Tyne Regular insulin provider 08/04/2019 08:30 156 Non-Fasting RN Ortg Entered: 08/04/2019 09:08 EST RN 08/02/2019 06:30 97 Non-Fasting MLP Orig Entered: 08/02/2019 08:16 EST MLP 08/01/2019 06:30 103 Non-Fasting MLP Orig Entered: 08/01/2019 09:00 EST alla MLP 07/31/2019 06:15 108 Non-Fasting MLP Orig Entered: 07/31/2019 08:36 EST Ma MLP Sa02: Nit /1mi ValuerAl Ak provider 07/30/2019 09:30 NYM 98 Room Air MD Orig Entered: 07/30/2019 12:59 EST MD 07/28/2019 20:28 NYM 98 RN Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 08:57 NYM 98 RN 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 =M. MLP 07/23/2019 06:30 NYM 96 Room Air MLP Orig Entered: 07/23/2019 08:33 EST MLP 07/09/2019 12:49 NYM 97 Room Air ■ MLP Orig Entered: 07/09/2019 12:51 EST MLP Height Generated 08/10/2019 11:02 by Bureau of Parsons NYM Page 2 of 3 EFTA00059447 Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Data II= Inches Cm Provider 07/09/2019 12:49 NYM 70.0 * 177.8 MLP Orig Entered: 07/09/201912:51 EST a MLP Weight: D.A.Ltt Emit 1n Kg Weicc .In1 Provider 07/30/2019 09:30 NYM 194.2 88.1 ~nip 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 a MLP Generaled 08/10/2019 11:02 by Bureau of Prisons - NYM Pass Set 3 EFTA00059448 Bureau of Prisons Health Services PPDs Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD j,ocation Provider Reading• Induration 07/06/2019 21:39 Right Forearm C 07/09/2019 12:47 0 mm INS MLP Orig Entered: 07/06/2019 21:43 EST Odg Entered: 07109/2019 12:47 EST MI MLP Total: 1 Generated 08/10/2019 11:02 by RNAOP/IDC Bureau of Prisons - NYM Page I 011 EFTA00059449 JULY 2019 76316454 EPSTEIN, JEFFREY Medication Administration Record Medication Orders 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 rm • ob. 07r10/19 PRN 1421 Infect neulz: Insulin st bcute-toousty per Exp. Dab altding ocr,..:J: bock° Cary ^•p'J Ilna^• for 7 07(31119 days 1001 NYM 122148- NM/ tuff) Reg (10 IC)1CR istiersaa Oct Date AID 07f31119 PRN 1000 bjaa tegul.ra tnacdln aubcutanooLraty par Fes. Data slItEng scale: oath morning for 7 days "'PM 08/07/19 Ono— 09S9 NYM 122160- NYM Lnu:n Reg (00 M-)100 lINITS/ML Lnj -PlovideTsn-YJ = Documentation Codes: ORO = Order I NI = Dose Not Indcated Pt. Name: EPSTEIN, JEFFREY DOB: 0112043 Regdeabon St 76318-054 11:02 EST Report infornallon Is current as of the 4810 MCI tune of printing: 08/100019 EFTA00059450 76318-054 EPSTEIN. JEFFREY Medication Administration Record AUGUST 2019 Medication limo 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. Dato IC/ 07(31119 PAN 1090 Ir*st tesailas hmu5n subcutaneously por Esp. On sCdIng scale: each moralni; for 7 days "'pw 01/07119 Cne"' 0959 MYM 172160. MYM Ustaat Reg (10 Ml..) 100 UNITSIMI. Provider:: YJ =M" Documentation Codes: ORD = Cider I NI r-. Dose Not Indicated Reg's-Batton P: 76318-054 Pt. Name: EPSTEIN. JEFFREY DOB: 01/20/53 Raport Inftxmalion is amtell es of the data and limo ot printing- 08/10/2019 11:02 EST EFTA00059451 Bureau of Prisons Health Services Devices and Equipment Start Date: 07/07/2019 Stop Date: owl012019 Reg #: 76315-054 Inmato Name: EPSTEIN, JEFFREY EDWARD Auks/Equipment Start Date Stop Dat0 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 Page 1 of 1 Generated 0811012019 11:02 by RNAOPADC Bureau of Prisons - NYM EFTA00059452 Bureau of Prisons Health Services Pain Management Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD lagg intervention Pain Quality Location Ea Post Provider 07/12/2019 13:25 MEDROL DOSE PACK Shooting Back-Middle 5 MD Orig Entered: 07/1212019 13:28 EST MD Generated 09/102019 11:02 by RN/IOPADC Bureau of Prisons - NYM Page 1 of 1 EFTA00059453 Bureau of Prisons Health Services Modified Diet Re uest Types of Diets: Clear Liquid Exp Date: Low Fat Exp Date: Mechanical Soft Exp Date: Low Cholesterol Exp Date: Low Triglyceride Exp Date: Renal Exp Date: Full Liquid Exp Date: Sodium Controlled Exp Date: Snack Exp Date: Diabetic Exp Date: Calorie Controlled Exp Date: X Other. FISH ALLERGIES. Exp Date: 07/30/2020 Comments: Health Service Staff EPSTEIN, JEFFREY EDWARD 76318-054 07/30/2019 Inmate Name Reg# Date Generated 07/3012019 14:57 by MD Bureau of Prisons NYM Page 1 of 1 EFTA00059454 Bureau of Prisons Health Services Allergies Reg #: 78318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Allergy Pate Noted Reactlog No Known Allergies 07/06/2019 Orig Entered: 07/06/2019 21:40 EST Total: 1 Generated 08/10/2019 11:02 by Bureau of Prisons • NYM Page 1 of 1 EFTA00059455 Bureau of Prisons Health Services Patient Education Assessments & Topics Reg IS: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Assessments Assessment Learns Rest Ay primary I anguage Years of Education FiarfietSigntucatign Provider 07/09/2019 Speaking/Listening English 12 None 0rig Entered: 071091201912:52 EST M. Total: 1 Topics pate Initiated Format Handout/Toplq Outcome Provider 07/3012019 Counseling Access to Care Verbalizes Understanding Orig Entered: 07/30/2019 13:33 EST 07/30/2019 Counseling Plan of Care Verbalizes Understanding Orle Entered: 07/30/2019 13:34 EST 07/28/2019 Counseling Plan of Care Verbalizes Understanding Orig Entered: 07/28/2019 07:22 EST 07/28/2019 Counseling Plan of Care Verbalizes Understanding (prig Entered: 07/28/2019 20:30 EST 07/24/2019 Counseling Access to Care Verbalizes Understanding Orig Entered: 07/24/2019 13:23 EST ME. 07/24/2019 Counseling Preventive Health Verbalizes Understanding Ofig Entered: 07/24/2019 13:23 EST a 07/23/2019 Counseling Access to Care Verbalizes Understanding Orig Entered: 07/23/2019 09:04 EST -07123/2O1-9--- Counsaling Plan of -Care Verbalizes Understanding Orig Entered: 07/23/2019 09:04 EST 07/14/2019 Counseling . Diagnosis Verbalizes Understanding Orig Entered: 07/14/2019 18:11 EST 07/12/2019 Counseling Diagnosis Verbalizes Understanding Generated 08/10/2019 11:02 by RN/IOPI1DC Bureau of Prisons - NYM Page 1 of 2 EFTA00059456 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Topics HandoutfTooic Outcome Provider Pate Initiated Format Ortg Entered: 07/12/2019 13:33 EST Total: 10 Page 2 oft Generated 08/1012019 11:02by RNnOWIDC Bureau of Prisons • NYM EFTA00059457 Bureau of Prisons Health Services Blood Glucose Begin Date: 07/07/2019 End Dato: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD (Reference Range: Random or Fasting 70 - 100, 2 hour post-prandial 70 - 140) DAR lama Yalua IY1211 Comments 08/04/2019 08:30 NYM 156 Non-Fasting Orig Entered: 08/04/2019 09:08 EST RN 08/02/2019 08:30 NYM 97 Non-Fasting Orig Entered: 08/0212019 08:16 EST =11 MLP 08/01/2019 06:30 NYM 103 Non-Fasting Orig Entered: 08/01/2019 09:00 EST MLP 07/31/2019 08:15 NYM 108 Non-Fasting Orig Entered: 07/31/2019 08:36 EST MEM MLP Total: 4 Generated 08/10/2019 11:02 by RN/IONDC Bureau of Prisons - NYM Page 1 of 1 EFTA00059458 Bureau of Prisons Health Services Health Problems Reg 01: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Axis Code I'm', Code Diagialia Status. Descnotion Current HyperilpIdemla, unspecified 07/12/2019 13:48 EST MD ICD-10 E785 07/12/2019 Current HYPERTRIGLYCERIDEMIA Sleep apnea MD ICD-10 G4730 07/12/2019 Current 07/12/2019 13:56 EST Essential (primary) hypertension MD ICD-10 110 07/30/2019 Current 07/30/2019 13:13 EST BY HX. Constipation, unspecified MLP ICD-10 K5900 07/09/2019 Current 07/09/2019 12:58 EST Low back pain MD ICD-10 M545 07/12/2019 Current 07/12/2019 13:30 EST Neuralgia and neuritis, unspecified MD ICD-10 M792 07/12/2019 Current 07/12/2019 13:30 EST No Diagnosis PhD/Chief I DSM-IV No Dx 07/09/2019 Current 07/09/2019 10:28 EST 1.1.1 syc o ogis Prediabetes MD ICD-10 R7303 07/30/2019 Current 07/30/2019 13:26 EST Injury, unspecified MLP ICD-10 T1490 07/23/2019 Current 07/23/2019 09:04 EST a RIO self inflicted injuries. Body mass Index (BMI) 27.0.27.9, adult MD ICD-10 Z6827 07/30/2019 Current 07/30/2019 13:14 EST Total: 10 Page 1 or 1 Generated 08/10201911:02 by RNIIOP/iOC Bureau of Prisons - NYM EFTA00059459 Bureau of Prisons Health Services Clinical Encounter Reg #: 76318.054 Inmate Name: EPSTEIN. JEFFREY EDWARD Sex: M Race: WHITE Facility: NYM Date of Birth: 01/20/1953 Provider: MD Unit: Z05 Encounter Date: 07/12/2019 13:10 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: MD Chief Complaint: ENDO/LIPID Subjective: 66 YR OL HITE MALE WITH HX OF HYPERT CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 . STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS EIR GI SIDE EFFECTS. HX OF O UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE Y HAS L4 - L5 SEVERE SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES. SURGICAL HX: NONE MENTAL HEALTH HX: Pain: Yes Pain Assessment Date: 07/12/2019 13:25 Location: Back-Middle Quality of Pain: Shooting Pain Scale: 5 Intervention: MEDROL DOSE PACK Trauma Date/Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology OBJECTIVE: Exam: General Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic. Disheveled, Unkempt, Acutely III Nutrition Ho: Appears Obese Genet/tied 07/12/2019 bk20 by Bureau of Prisons • NYM Page 1 of 3 EFTA00059460 Inmate Name: EPSTEIN. JEFFREY EDWARD Reg ft 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 B Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back Yes: Tenderness Neurologic 41) Cranial Nerves (CN) Yes: W Systemn ithi Normal Limits Motor -General Yes: Normal Exam 0: 4 0,120 ASSESSMENT: Constipation, unspecified. K5900 - Current Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Sleep apnea, G4730 - Current 0let PLAN: New Medication Orders: Bra Medication Order Date Prescriber Order Magnesium Hydroxide Susp 07/12/2019 13:10 30 CC Orally • Two Times a Day PRN x 2 day(s) Indication: Constipation, unspecified MethylPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 AS DIRECTED Orally - daily x Pack 21 tab) 6 day(s) Indication: Neuralgia and neuritis, unspecified Disposition: Generated 07/12/2019 14:20 by MD Bureau of Prisons • NYM Page 2 of 3 EFTA00059461 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM l Encounter Date: 07/12/2019 13:10 Provider: 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 Formal Handout/Topic Provider Outcome 07/12/2019 Counseling Diagnosis Verbalizes Understanding Copay Required:No Cosign Required: No TelephoneNerbal Order: Completed by n 07/12/2019 14:20 Generated 07/12/2019 14:20 by MD Bureau of Prisons NYM Page 3 of 3 EFTA00059462 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 Dale: 07/12/2019 13:10 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 OL HITE MALE WITH HX OF HYPERT CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , . STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS 9, EIR GI SIDE EFFECTS. HX OF O iS)14ii LIVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. '•1 q? HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE Y HAS L4 - L5 SEVERE SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMI S. SURGICAL HX: NONE MENTAL HEALTH HX: Pain: Yes Pain Assessment Date: 07/12/2019 13:25 Location: Back-Middle Quality of Pain: Shooting Pain Scale: 5 Intervention: MEDROL DOSE PACK Trauma Date/Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: Seen for clinic(s): Endocrine/Lipid. Pulmonary/Respiratory. Orthopedic/Rheumatology Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology OBJECTIVE: Exam: General Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic. Appears in Pain, Writhing in Pain, Pale. Pallor, Cyanotic. Diaphoretic. Disheveled, Unkempt. Acutely III Nutrition No: Appears Obese Generated 07/12/2019 14:20 by MD Bureau of Prisons • NYM Page 1 or 3 EFTA00059463 Inmate Name: EPSTEIN. JEFFREY EDWARD Reg )4: 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 d.Rhythm (RRR). Normal S1 and S2 No: M/R/G Abdomen Auscultation Yes: Normo-Active 8 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: EK.# Ke_dkation Order Date Prescriber Order Magnesium Hydroxide Susp 07/12/2019 13:10 30 CC Orally - T o Times a Day PRN x 2 day( ) Indication: Constipation, unspecified MethylPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 AS DIRECTED ly - daily x Pack 21 tab) 6 day(s) Indication: Neuralgia and neuritis, unspecified Disposition: Generated 07/12/2019 14'20 by MD Bureau of Prisons • NYM Page 2 of 3 EFTA00059464 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg If: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: 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 Pr_ovides, Outcome 07/12/2019 Counseling Diagnosis Verbalizes Understanding Copay Required: No .,- . --.) Cosign Required: No i . TelephoneNerbal Order: Completed by D.,•n 07/12/2019 14:20 Generated 07/12/2019 14 20 by MO Bureau of Prisons • NYM Page 3 of 3 EFTA00059465 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 71 8-054 Date of Birth: 01/20/1953 Sox: M Race: Encounter Date: 07/14/2019 17:36 Facility N Amendment mado to this note by MD on 07/14/2019 18:11. Bureau of Prrsons - NYM EFTA00059466 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Reg /t: 76318-054 Date of Birth: 01/20/1953 Sex: Facility: NYM Note Date: 07/12/2019 09:08 Provider. MD Unit: ZO5 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: Rx# Medication Order Date prescriber Order Dccusate Sodium Capsule 07/12/2019 09:06 TAKE ONE 1r t MG CAP Orally - Two Times Day x 30 day(s) Indication: Constipation, unspecified Discontinued Medication Orders: adt Medication Order Date c ibe 121757-NYM Bisacodyl E.C. 5 MG TAB 07/1212019 09:06 Take one tatAit (5 MG) by mouth at bedtime AS NEEDED for 10 days Discontinue Type: When Pharmacy Processes Discontinue Roason:discontinue Indication: Copay Required: No Cosign Required: No TelephoneNerbal Order No Completed by MD on 07/12/2019 09:10 Generated 07/12/2019 09:10 by MD Bureau of Prisons - NYM Page 1 of 1 EFTA00059467 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- MD Unit: ECG Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider. MD MED CL:1 NO CCC APPT. Discontinued Laboratory Requests: Details Frequency Due Date Lab Tests-H-Hemoglobin AlC One Time 08/05/201900:00 R• Lab Tests-C-CBC w/diff Lab Tests-L-Lipld Profile Lab Tests-C-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Rellex to Microscopic Additional Information: 66 y/o male, elevated BP Labs requested to be reviewed by: MD New Laboratory Requests: DataHa Frequency Rue 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-Comerehensive Metabolic Profile (CMP) New Radiology Request Orders: Details Frequency End aatft Due Pate Edo* General Radiology-Chest-2 Views One Time 07/25/2019 Ftouline Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH NO PMHX REFERRED FOR ROUITNE CXR. Copay Requlrod:No Cosign Required: No TelephoneNerbal Order: No Completed by MD on 07/07/2019 00:30 Generated 07/072019 00:30 by MD Bureau of Prisons • NYM Panto% 1 EFTA00059468 Bureau of Prisons Health Services History & Physical Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 78318464 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Dale: 07/09/2019 12:35 Provider BIM MLP Unit r1 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): 104- Mate Sexual Partners (Last 5 Yrs): 0 Condom Use: Sometimes Soxual Contact With HIV+ Individual: No Blood Product Transfusion: No Travel Outside US: Yes Tattoos: No Comments: Born in US High school diploma Banker Traveled to Paris x 3 weeks up until arrest No tattoos Generated 07/09/2019 13:03 by M. MLP Bureau of Prisons - NYM 1el 13 EFTA00059469 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 7; 18-054 Date of Birth: 01/20/1953 Sex: M : WHITE Facility: Encounter Date: 07/09/2019 12:35 Provider . MLP Unit HIV History: When Tested: 2019 Test Result: Negative Whon 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 Gantt-aux' 07/022019 13:03 by an Bureau of Prisons NYM 2of 13 EFTA00059470 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 MB MLP Unit: 14 Mental Health: Level of Consciousness: Alert and Oriented Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Hx of Mental Health Treatment: None Hx of Head Injury: None Current Mental Health Treatment: No Current Mental Health Complaint: No Hx of Loss of Consciousness: No Hx of Hearing Voices: No Past History of Suicide Attempt: No Current Suicide Ideation: No Suicide Prevention Initiated:No Comments: Substance Use History: Denied Current Painful Condition: Denied Other Health Issues: Current Medical Conditions: Other Current Treatments: Pregnant: N/A Dental Condition: Denied Generated 07/09/2019 13:03 by MLP Buttenu of Prisons-NYM Page 3 ad 13 EFTA00059471 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: : WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit 1101 Observations: Draining Skin Lesions: No Signs of Lice: No Signs of Scabies: No Signs of Recent Trauma: No Recent Tattoos: No Needle Marks: No Signs of Rash: No Open Sores: No Wounds: No Body Deformities: No Tremors: No Sweating: No Comments: Generated 07,09/2019 13:03 by Ea MLP Bureau of Prisons - NYM Page 4 of 13 EFTA00059472 Reg #: 76318064 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Provider: 111.1. MLP Unit: H01 Encounter Date: 07/09/2019 12:35 Immunizations: Hepatitis A and B (TwinRx) Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider:MEI'. 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: Routo: Exp Dt: Comments: Smallpox Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Tetanus Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Generated 07/09/2019 13:03 by MLP Bureau of Prisons - NYM 5d 13 EFTA00059473 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: : WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider. IMIll ekILP Unit: F01 Immunization Date: Provider: IMIE. MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Varicella Series Administration: History Unknown, Not Administered Documented Date: 07/09/201912:51 EST Immunization Date: Provider: NEB MLP Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Temperature: pa a Time Fahrenheit celsjua 1,0cation Provider 07/09/2019 12:49 NYM 97.3 36.3 Oral MLP Pulse: Mgt Time Rate Per Minute Location Rfivthrrt Provider 07/09/2019 12:49 82 Via Machine Regular MLP Respirations: io Time Rate Per Minute Provider 07/09/2019 12:49 NYM 16 MLP Blood Pressure: PAO Brae yawn Location. Position Cuff Size Provider 07/09/2019 12:49 NYM 117/66 Right Arm Sitting Adult-regular MLP SaO2: to Time Value(%) Ali Provider 07/09/2019 12:49 NYM 97 Room Air MLP Height: Data Time Inches Cm Provider 07/09/2019 12:49 NYM 70.0 177.8 MLP Generated 07/092019 13.03 by a MLP Bureau of Prisons - NYM Pali 6 of 13 EFTA00059474 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: ea: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: . MLP Unit: H01 Date Time in_cheS _Ca Provider Weight: Data Time 1.bs Ka Waist Circum Emitter 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: Pate gd Yrs OccUrtation Learns Best By Peqa if on 07/09/2019 12 Balker 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: Numbor of Siblings: 1 Significant Illnesses: Comments: Past Hospitalization: Reason Location When Acute Appendicitis Mount Sinai Hospital 1990 Complications: None Comments: Head: Normal: Yes Comments: Ger-waled 07/C9/2019 13.03 by MLP Bureau of Prisons • NYM Page 7 of 13 EFTA00059475 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg*: 318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: Encounter Date: 07/09/2019 12:35 Provider: MLP Unit 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 Fund' Vessels Discs Sharp Margins: Yes Fundi Vessels Grounds Abnormal: No Eyes Comments: Vision Screen 07/09/2019 12:52 Blindness: With Corrective Distance Vision: OD: 100 OS: 70 OU: OD: OS Near Vision: OD: OS: OU: OD: OS: Ishihara Color Test: Tonometry: L: R: Comments: Needs evaluation with optometrist. Ears: Right Ear: Canal patent Left Ear: Canal patent Ears Comments: Nose: Nares Patent: Yes Septum Midline:Yes Septum Intact: Yes Drainage/Discharge: No Polyps: No Nose Comments: Generated 07/09/2019 13:03 by tat? Bureau of Prisons - NYM Page 6 of 13 EFTA00059476 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01120/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/201912:35 Provider: Ia. MLP Unit: 1 Mouth Lesions:No Oral/Buccal Mucosa:Yes Gums Normal: Yes Tonsils Present:Yes Tonsils Normal: Yes Pharynx: Normal Color Teeth Poor Dentition: No Teeth Count:Mostly Present Dentures: No Mouth Comments: Cranial Nerves: Intact II-Xll: Yes Cranial Nerves Comments: Neck: Full ROM:Yes Masses/Nodes: No Trachea: Midline Thyroid: Normal Size Comments: Breasts: Normal: Yes Masses:No Tenderness:No Scars: No Dimpling:No Nipple Discharge: No Nipple Retraction:No Instructions for Self Breast Exam Given: No Comments: Generated 07/09/2019 13.03 by MLP Bureau of Prisons - NYM Page 9 of 13 EFTA00059477 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 4: 76, 18-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: HO Thorax: Contour Normal:Yes Increased AP Diameter: No Asymmetrical Expansion:No Lungs Clear: Yes Wheezes: No Crackles: No Rhonchl: No Rates: No Accessory Muscle Use: No Comments: Spine: Deformity: No Full ROM:Yes Tondernoss:No Comments: Cardiovascular: RRR: Yes Normal S1/S2: Yos Murmurs: No Carotid Bruits:No JVD: No Arteries: Right Left Radial: Femoral: Dorsalis Pedis: Post. Installs: Comments: Goaerale\7 07/09/2019 13:03 by MLP Bureau of Prisons • NYM Page 10 of 13 EFTA00059478 Reg #: 7 18-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: Provider: MLP Unit 1 Encounter Date: 07/09/201912:35 Abdomen: Normal Contour:Yes Scaphold: No Obese: No Gravid: No Hernias: No Bruits: No Masses:No Scars: No Tenderness: No Organomogaly: No Active Bowel Sounds: Yes Comments: Extremities: Nails Clubbing: No Nails Cyanosis: No Lower Extremity Edema - Right: None Lower Extremity Edema - Left: None Atrophy: No Amputations: No Other Deformities: No Varicosities:No Calf Tenderness: No Pulse Deficit: No Strength: Fight Left Arm: Log: Full ROM: Right Arm: Yes Yee Leg: Yes Yes Comments: MLP Etwoau of Prisons NYM P. 11 of 13 Gene:rood 07/0912019 13:03 by EIM. EFTA00059479 Reg it 76 18-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: Provider. a MLP Unit: Encounter Date: 07/09/2019 12:35 Reflexes: flight ken Biceps: Patellar: Brachioradialis: Achilles: Sensation: Vibratory: Yes Light Touch: Yes Pin Prick: Yes Comments: GU: Chaperoned By: Rectum: Not Done Comments: Refused. Male Genitalia: Not Done Comments: Refused. Skin: Normal:Yes Rash: No Redness:No Abnormal Pigmentation: No Abnormal Lesions/Growths: No Comments: Lymphatics: Adenopathy: No Comments: Potential Items For Follow-up: Item Travel Outside US Other Infectious Disease History Rectum Not Done Male Genitalia Not Done PPD Administration Not Performed Comments: Patient has a history of constipation. Page 12 of 13 Generated 07/09/2010 13:03 by . MLP Bureau of Prisms - NYM EFTA00059480 Reg #. 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01120/1953 Sex: : WHITE Facility: NYM Date: 07/09/2019 12:35 Provider Unit: H01 Encounter Cleared For Food Services: Yes Health Problems Newly Identified During This Encounter: Health Problem Constipation, unspecified - Current - Now Medication Orders: # Medication. Order Date altadindfli Bisacodyl E.C. Tablet 07/09/2019 12:35 5 mg Ordy et bedtime PFtN 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 TelophoneNerbal Order No Completed MLP on 07/09/2019 13:03 Requested to be cosigned by NM= MD. Cosign documentation will be displayed on the following page. Generated 07/09/2019 13:03 by MEIMLP Bureau of Prisons • NYM Pio 13 of 13 EFTA00059481 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: OD: OS: OU: Near Vision: With Corrective Distance Vision: OD: OS: OU: Near Vision: OD: OS: OU: Present Glasses - Distance Refraction - Distance Cylinder Axis Add Sphere Cylinder Axis Sphere R: R: L: L: Color Test Tonomotry: R: L: Comments: Needs evaluation with optometrist. OrIg Entorod: 07/09/2019 12:54 EST Ma MLP Generated 08110/2019 11:02 by Bureau of Prisons - NYM Pap 1el I EFTA00059482 Bureau of Prisons Health Services Immunizations Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Immunization Immuolzalloanslle Administered. Location Dosage Drug Mfg, Txp 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 1a51 EST • MU' Smallpox Series History Unknown Orly Entered: 07/09/2019 12:51 EST MLP Tetanus History Unknown Orig Entered: 07/09/2019 12:51 EST MLP Varicella Series History Unknown Orig Entered: 07/09/2019 12:51 EST MLP Total: 5 Generated 08/10/201911:02 by RN/IOP/IDC Bureau of Prisons - NYM Page 1 of 1 EFTA00059483 Bureau of Prisons Health Services Medical Duty Status Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD ?Tr , • Houslog•Stattre: tt" tr - . a. except _meals pill line _treatments Exp. Date: confined to the living quarters .. bathroom privileges only Exp. Date: on complete bed rest:.. airborne infection isolation Exp. Date: 10/09/2019 X cell: eeN on first floor single cell X lower bunk Exp. Date: other Ptinta tli;g4DniiitsTSel1/2 :ttri: Exp. Date: all spoil:4 wstuhutfting: _upper body lower body Exp. Date: softball Exp..Date: ...ctsychavascular exercise: _running _jogging _walking _football _basketball _handball stationary equipment ' 'other: Exp. Date: • O urS areigiga niiiiig •';' falergiffinagra Start Date End Date elum Date Equipment C-Pap 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. • • ...-44k;:.:4":, W m tali 1rtatts:Iriart r;:dutuSk..;.t. Cleared for Food Service: Yes X No Restrictions Comments: N/A MD 07/30/2019 Health Services Staff Date Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 76318.054 Quarters: Z04 ALL EXPIRATION DATES' RE AT 24:00 Generated 0811012019 11:02 by Bureau d Prisons - NYM Page I oil EFTA00059484 Bureau of Prisons Health Services Medical Duty Status Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD _pill line treatments Exp. Date: confined to the living quarters except _meals on complete bed bathroom privileges only Exp. Date: single cell X lower bunk airborne infection isolation Exp. Date: 10/09/2019 X cell: cell on fi t floor. other. Exp. Date: rf itag,:frit:FL effOrahrffiallo it idrictrOrign . 5?.i.t:' 1.1. WI :a '.•••••;:' all sports„;:' Exp. Data: weigtitfifting: upper body lower body Exp. Date: -cardioyascular exercise: running _jogging _walking softball Exp. Date: football basketball _handball _stationary equipment Exp. Date: haverkgfcMirgaa61PIAglirfirOWerplass'esstoliyak&itaiW: ti Wk.,..124satta ki Aratatjai sitaterfa:r 7rt,WA /4 3 Cleared for Food Service: Yes X No Restrictions Comments: N/A MLP 07/09/2019 Health Services Staff Date Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 33: 76318-054 Quarters: Z04 ALL EXPIRATION DATES ARE AT 24:00 Generated 08/10/2019 11:02 by BUIVIU or Prisons • NYM Page 1 of 1 EFTA00059485 Bureau of Prisons Health Services Medication Summary Historical Begin Date: 07/07/2019 End Date: 0B/10/2019 Complex: NYM—NEW YORK MCC Reg #: 76318-054 Quarter: Z04-206LAD Inmate: EPSTEIN, JEFFREY EDWARD this report. Medications listed reflect prescribed medications from the begin date to end date on 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. Ili MLP Start: 07/09/19 Exp: 07/19/19 D/C: 07/12/19 Pharmacy Dispensings: 10 TAB i 32 days Docusate Sodium 100 MG Cap Take one capsule (100 MG) by mouth twice daily for 30 days Rx#: 121823-NYM Doctor. MD Start 07/12/19 Exp: 08/11/19 Pharmacy Dispensings: 60 CAP ir 29 days Docusate Sodium 100 MG Cap Take one capsule (100 MG) twice daily b mouth with plenty of water Rx#: 122084-NYM Doctor. MD Start: 07/26/19 Exp: 01/22/20 Pharmacy Dispensings: 30 CAP In 15 days Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML shake well take 2 tablespoonful twice dal b mouth Rx#: 121835-NYM Doctor. MD Start: 07/12/19 Exp: 07/14/19 Pharmacy Dispensings: 473 ML in 29 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 Pharmacy Dispensings: 473 ML in 11 days methyiPREDNISolone 4 MG Tab ( 21 count Pack) Take the tablet by mouth as directed fbc#: 121836-NYM Doctor. MD Start: 07/12/19 Exp: 07/18/19 Pharmacy Dispensings: 21 tab in 29 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 11 days Generated 08/10/201911:02 by Bureau of Prisms - NYM Page 1 of 2 EFTA00059486 Begin Date: 07/07/2019 End Date: 08/10/2019 Complex: NYM—NEW YORK MCC Quarter. Z04-206LAD Reg #: 76318-054 Inmate: EPSTEIN. JEFFREY EDWARD Active Prescriptions Omega 3 (Vascepa) 1 GM Capsule food Take two capsules (2 GM) twice daily b mouth with Rx#: 121885-NYM Doctor: MD Exp: 01/13/20 Pharmacy DispensIngs: 180 Cap in 24 days Start: 07/17/19 Insulin Reg (10 ML) 100 UNITS/ML Inj daily "'pill line*" for 7 days "'pill line*" Inject regular Insulin subcutaneous/ er slidin scale: twice Rx#: 122148-NYM Doctor: MD Exp: 08/06/19 D/C: 07/31/ 19 Pharmacy DispensIngs: 0 ML in 11 days Start: 07/30/19 Insulin Reg (10 ML) 100 UNITS/ML Inj g for 7 days — *pill lino— "'pill line Inject regular insulin subcutaneous) er sliding scale: each mornin Rx#: 122160-NYM Doctor: MD Exp: 08/07/19 Pharmacy DIspensIngs: 0 ML in 1 days Start: 07/31/19 Bureau of Prisons - NYM Par 2of 2 Generated 08/102019 11:02 by EFTA00059487 Bureau of Prisons Health Services Dental Health History Screen Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD 01/20/1953 Sex: M ce: WHITE Facility: NYM Date of Birth: 07:54 Provider. DDS Unit H01 Encounter Date: 07/26/2019 ASSESSMENTS: Health Problems as of Dental Health History Encounter date: 07/26/2019 07:54 Health Problems Health Problem atehil Hypertiplderrda, unspecified Current HYPERTRIGLYCERIDEMIA Steep apnea Current Constipation, unspecified Current Low back pain Current Neuralgia and neuritis, unspecified Current No Diagnosis Current Injury, unspecified Current R/0 self inflicted injuries. Medical History as of Dental Health History Encounter date: 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 Gorarated 07/26,2019 07:59 by DOS Bureau of Prisons • NYM Page 1 of 3 EFTA00059488 Reg #: 7631 Inmate Name: EPSTEIN, JEFFREY EDWARD Facility: NYM Date of Birth: 01120/1953 Sex: Ivi Provider alliaDDS Unit: H01 Encounter Date: 07/26/2019 07:54 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: Chiamydla In 2015, treated Chicken pox in childhood Other Health Issues: Other Medical Conditions And Treatmont: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 Methamphotamine: No Tobacco products: No Other drugs: No Sensitive tooth: No Bleeding gums: Yes Food impaction: Yes Pain around ear: No Toothache: No Wear partial dentures: No Unusual sounds while eating: No Snoring: Yes Blisters on lips or mouth: No Clenching or grinding: Yes Swelling or lumps In mouth/throat: No Burning tongue: No Bad breath: No Decayed teeth: No Loose teeth: No Wear dentures: No None: No Comments: DDS Eturuau of Prison, • NYM Pan 2 of 3 Generated 07128/2019 07:59 by EFTA00059489 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/26/2019 07:54 Provider. ADDS 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: twice da4 for 30 days Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take one capsule (100 MG) by mouth (2 GM) twice daily by north with food Omega 3 (Vascopa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules OTCs: Listing of all known OTCs this inmate is currently taking. Instructed inmate how to obtain medical, dental, and mental health care. Copay Required:No Cosign Required: No TelephoneNerbal Order No Completed by DDS on 07/26/2019 07:59 DOS Bureau of Prison NYM p.o.3 of 3 Generated 07/26/2019 07:59 by EFTA00059490 Bureau of Prisons Health Services Dental A&O Exam Reg #:. 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Facility: NYM Provider. DS Unit H01 Encounter Date: 07/26/2019 07:47 Reviewed Health Status: Yes Occlusion: Class I Oral Hygiene: Fair CPITN: 3 2 1 3 3 2 3 Hard and soft tissue examination performed and documented on BP618 form: Yes Head & Neck/Soft Tissue within normal limits? No Comments: moderate to advanced upper posterior gingival recession Decayed: Missing: Filled: 0 1 14 Comments: Lower anterior crowding Approved for hygiene appointment and radiographs: Yes Instructed inmate how to obtain routine and emergency dental care. Oral hygiene instructions Nen: Yes Dental A&O Screening Exam findings entered on EPSTEIN, JEFFREY EDWARD by S on 07/26/2019 07:47. Generated omenoie 08:00 by ODS Bureau of Prisons NYM papaldl EFTA00059491 Bureau of Prisons Health Services Dental Soap/Admin Encounter Inmate Name: EPSTEIN. JEFFREY EDWARD Reg ti: 76318-054 01/20/1953 Sex: Facility: NYM Date of Birth: Provider: Dental Asst Unit: Z05 Encounter Date: 07/18/2019 13:48 Screening encounter at Dental Clinic. Reason Not Done: Unavailable e dental clinic. Comments: Patient has had several call outs for his Dental A & 0 screening but has not been escorted to Cosign Required: No Completed by Dental Asst on 07/19/2019 13:49. Dental Bureau of Prisons • NYM Page 1 of 1 Generated 07/19/201913:49 by EFTA00059492 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 Ycrk Collected 07/09/2019 13:34 Reg U 76318-054 Order Un Received 07/10/2019 10:44 DOB 01/20/1953 Provider MD Reported 07/10/2019 14:46 Sex M LIS ID 188191004 CHEMISTRY Sodium 137 137-148 mmol/L 4.7 3.5-5.0 mmoUL Potassium 99 99-114 mmol/L Chloride 27 22-30 mmoUL CO2 17 7-22 mg/dL BUN 1.05 0.66-1.25 mg/dL Creatinine eGFR (IDMS) >60 GFR units measured as mL/min/1.73 m"2. If African American multiply by 1.210. A calculated GFR <BO suggests chronic kidney disease if found over a 3 month period. 9.8 8.5-10.9 mg/dL Calcium 102 70-110 mg/dL Glucose H 57 11-55 U/L AST 62 11-66 U/L ALT Alkaline Phosphatase 64 41-133 U/L 1.1 0.2-1.3 mg/dL Blirubin, Total 7.3 6.0-8.2 g/dL Total Protein 4.4 3.6-5.1 g/dL Albumin 2.9 2.0-3.7 g/dL Globulin Alb/Glob Ratio 1.50 1.00-2.30 Anion Gap 10.2 9.0-19.0 BUN/Creat Ratio 16.1 5.0-30.0 Cholesterol H 216 <200 mg/dL Triglycerides H 413 10-150 mg/dL Calculation cf LDL is not appropriate for samples with a triglyceride greater than 400 mg/dL. Therefore the LDL is not calculated. L 31 40-60 mg/dL HDL Cholesterol Choi/HDL Ratio H 6.9 0.0-4.0 HEMATOLOGY WBC 7.6 4.3-11.1 KfuL NRBC% 0.0 RBC 5.42 4.46-5.78 'NUL Hemoglobin 15.6 13.6-17.6 Hematocrit 47.8 40.2-51.4 MCV 88.2 82.5-96.5 IL MCH 28.8 27.1-34.9 P9 MCHC L 32.6 33.0-37.0 g/dL RDW-CV 12.8 12.0-14.0 Platelet 338 130-374 K/uL FLAG LEGEND L=Low Lt=Low Critical H=l-figh H!=High Cntical A=Abnorrnal Al =Abno al Critical Page 1 of EFTA00059493 U.S. Medical Center for Federal Prisons Federal t 1900 W. Sunshine Stree Bureau of Prisons Springfield, MO 65807 417-874-1621 ••• Sensitive But LInctassilled Facility MCC New York Collected 07/09/2019 13:34 Name EPSTEIN, JEFFREY Received 07/1012019 10:44 Order Un 5.47U Reg # 76318-054 Reported 07/10/2019 14:46 Provider. MD DOB 01/20/1953 LIS ID 188191004 Sex M HEMATOLOGY 6.9-10.6 IL 10.4 MPV Neutrophils % 58.7 Therapeutic decision making should be based on absolu te values, rather than percentages Lymphocytes % 25.0 cto Monocytes % 11.1 Eosinophils % 4.1 Basophils % 0.8 0.3 0.0-5.0 Immature Granulocytes % K/uL 4.4 1.9-6.7 Neutrcphits # K/uL 1.9 1.3-3.7 Lymphocytes # K/uL 0.8 0.3-1.1 Monocytes # K/uL 0.3 0.0-0.5 Eosinophits # K/uL 0.1 0.0-0.1 Basophils # 10"3/uL 0.02 0.00-0.50 Immature Granulocytes HEMOGLOBIN A1C 6.3 <5.7 Hemoglobin A1C 5.7 -6.4 Increased Risk > 6.4 Diabetes SEROLOGY Non-Reactive Non-Reactive RPR Results may be affecte d in patient s with severe ly advanc ed immunosuppression. =Abnormal Critical FLAG LEGEND L=Low LI=Low Critical H=High H!=High Critical A=Abnorrnal Al Page 2 or' 3 EFTA00059494 Federal U.S. Medical Center for Federal Prisons Bureau of 1900 W. Sunshine Street Prisons Springfield, MO 65807 417-874-1621 ***Sensitive But unclassified "' Facility MCC New York Collected 07/09/2019 13:34 Name EPSTEIN, JEFFREY Order Unit E06-547U Received 07/10/2019 10:44 Reg # 76318-054 Provider MD Reported 07/10/2019 14:46 DOB 01/20/1953 188191004 LIS ID Sex M HIV Negative Neaten HIV 1/2 Screening test - Soo confirm atory tostIng for Reactiv e results FLAG LEGEND L=Low L!=Low Critical H=High HI=High Critical A=Abnormal Al =Abnormal Critical Page 3 of EFTA00059495 Bureau of Prisons Health Services Cosign/Review Reg /!: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Sex: M Race: WHITE Date of Birth: 01/20/1953 16:58 Provider. Lab Result Receive Facility: NYM Encounter Date: 07/10/2019 CosIgnod bye MD on 07/14/2019 18:12. &IMAM of Prisons • NYM EFTA00059496 CDFRM BP-S358.060 MEDICAL TREATMENT REFUSAL SEP C6 FEDERAL BUREAU OF PRISONS U.S. DEPARTMENT OF JUSTICE 7-24.2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental CO Won, and release the Buroau of Prisons and Its employees from any and all liability for respecting and f• owing my expressed wishes and directions. MD 7-24-2019 Counseled by Date a is Sign Date Signatureof Wane s Signature Date NYM-NEW YORK MCC EFTA00059497 BP-A0618 A&O DENTAL EXAMINATION JUN 18 (initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Occlusion: Oral Hygiene: Good Fair , 00, CPITN: 3 3 2- 9 Head & Nock / Soft Tissue: 1 2 3 4 5 8 7 8 9 10 11 12 13 14 15 18 0 — 32 31 30 29 28 27 2825 21 23 22 21 20 19- 18 17 Classirmatlem D. apt I CL, F: ltd Pain Scale: /10 Dental Prostheses; at Intake: Yes CP ATI io z24,W Russicy, Di:. SW /2- /C5 /Ilea Type. Age: 1.0.--)g—r 0--• Ace) or Citi -011A5 Ci175d ul4 Cent:Mon: Intra-cral Photos Taken: Radiographs Taken: (Document findings on MO encrounter) Yes Yes CD 9 Instructed how to obtain urgent and non-urgent dental care Yes: 1 Noc Treatment Primites: None: Ncn-urgent Urgent Referred to Sick Cat non-urgent Radiographs authenzed: Prophylarig authorized: Yes i No PM: (Moroni valid 18 months from examinalion date) SW5: Panorex Pa t Name:, Dentst : sh n , D —Ccici -Jty E Nutt.: I institution:/ Date: Signature Block/Stamp: 7‘ 3 Isre US-`} MCC NEW YORK 7- 24 -1 9. DDta Ghlet uental r MCC New York PDF Presorted by P640) Replaces SP-A0(IIS 01JUN 10 EFTA00059498 Bureau of Prisons Health Services Clinical Encounter Reg #: 76318 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: ga dgg;,..VUITE Facility: NYM Provider: Ell=1=1. RN Unit: H01 Encounter Date: 07/28/2019 20:25 Nursing - Follow up encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: RN Chief Complaint Neuropathy - Tingling/Numbness of Extremity(ies) complaints or Subjective: Inmate seen for F/U after returning from attorney conference offers no new worsening S/S Mats ° My R hand still has pins and needles sometimes' No change in appearance from previous exam. Pain: No OBJECTIVE: Pulse: Rate Per Minuto Location Rhythm Provider Data lime 81 RN 07/28/2019 20:28 Respirations: Date nun Rate Per Provider 07/28/2019 20:28 NYM 14 RN Blood Pressure: Value Location Position Cuff Sin provider Date 21= 07/28/2019 20:28 NYM 157/91 SaO2: Mita Time Value(%), 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 Bureau of Prisons- NYM Page 1 of 2 Generated 07/28/201920:30 by RN EFTA00059499 Reg it 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Sex: illiSTE Facility: NYM Date of Birth: 01/20/1953 Provider. RN Unit H01 Encounter Date: 07/28/2019 20:25 Forow-up in 12-24 Hours Patient Education Topics: Handout/Topic Outcome Pate Initiated f ormiti 07/28/2019 Counseling Plan of Care Sim Verbalizes Understanding Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Compieted by RN on 07/28/2019 20:30 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 07/2812019 20:30 by RN Eturciou of Prisms - NW/ Pan 2 d 2 EFTA00059500 Bureau of Prisons Health Services Cosign/Review Reg #: 76318.054 Inmate Name: EPSTEIN, JEFFREY EDWARD WHITE Date of Birth: 01/20/1953 Encounter Date: 07/28/2019 20:25 Sex: Provid er: IIMIEN RN Race: Facility: NYM Cosigned by MD on 07/28/2019 20:50. Bureau of Prisons - NYM EFTA00059501 Bureau of Prisons Health Services Clinical Encounter Reg it: 76318.054 Inmate Name: EPSTEIN, JEFFREY EDWARD Facility: NYM Sex: larial iTE Date of Birth: 01/20/1953 H01 Provider. RN Unit: Encounter Date: 07/28/2019 06:51 Nursing - Triage Note encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: RN Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies) just doing what it Subjective: ' I woke up and I had no control over my Right arm for a few minutes it was wanted to dos Pain: No OBJECTIVE: Pulse: Time RAW Per Minute Location Rhythm Provider Bute 07/28/2019 06:57 82 Respirations: Pate ILnti Rate Per Minute Provider 07/28)2019 06:57 NYM 14 RN Blood Pressure: nate rime Value Location Position Cuff Size Provider 07/28/2019 06:57 NYM 138/80 SaO2: Data Time Valuef%). Air Provider 07/28/2019 06:57 NYM 98 RN Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 Skin General Yes: Within Normal Limits, Dry, Skin Intact Head General Yes: Symmetry of Motor Function, Atraumatic/Norrnocephalic No: Facial Asymmetry, Battle's Sign, Raccoon Eyes, Deformity Eyes General Yes: PERRLA, Extraocular Movements Intact Face General Yes: Symmetric Generated 07/28/2019 07:22 by RN Bureau or Prisons - NYM Peg.1 of 3 EFTA00059502 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Facility: NYM Sex: eP asWHITE Date of Birth: 01/20/1953 RN Unit 1101 Encounter Date: 07/28/2019 06:51 Provid er: Exam: Edema No: Ecchymosls, Numbness, Swelling, Periorbital 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 on Palpation R Yes: Normal Exam R, Full Range of Motion R, Non-Tender Radius / Ulna Yes: Normal Exam R, Full Range of Motion R Wrist/Hand/Fingers ion R, Swelling R Yes: Full Range of Motion R, Non-Tender on Palpat rness R, Laceration(s) R, Abrasion(a) No: Inflammation R, Ecchymosis R, Erythema R, Tende Contusion(s) R ROS Comments Right ann full sentenced ambulating independently C/ Received inmate AAOX3 In no acute distress, speaking in psyc obs through that has since subsided. Inmate interviewed in numbness after waking up from 'sleeping on my side' ogical deficits noted, no facial droop slurred speech or the slot V/S noted WNL, RR even and unlabored, no neurol phalan ges th bilaterally, slight swelling noted to right dysphagia, Inmate with Full ROM to all extremities with 4/4 streng at this time. nosis noted. Denies any pain numbness or tingling when compared to left, no edema, erythema or ecchyr Re-evaluate Blurred vision. Eyes PERRLA. MD on Call notified, Denies any Chest pain, Headache, Dizziness, SOB or 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: Outcome Pate Initiated format Handout/Tonic Verbalizes 07/28/2019 Counseling Plan of Care Understanding Page 2 of 3 RN Bureau of Prisons • NYM Generated 07/28/2019 07:22 by EFTA00059503 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Facility: NYM Sex: M Race: WHITE Date of Bldh: 01/20/1953 Unit: H01 Encounter Date: 07/28/2019 06:51 Provider: SRN Provider outcome Date Initiated Esimat Handout/Tonic Copay Required: No Cosign Required: Yes TelophoneNerbal Order: No Completed by RN on 07/28/2019 07:22 Requested to be cosigned by MD. page. Cosign documentation will be displayed on the following Bureau or Prisons - NYM Pie 3 of 3 Generated 07128/2019 07:22 by RN EFTA00059504 Bureau of Prisons Health Services Cosign/Review Reg ft 76:', 18-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Race: WhITE 01/20/1953 Sex: M Date of Birth: RN Facility: NYM 06:51 Provid er: Encounter Date: 07/28/2019 Cosigned bye MD on 07/2812019 20:51. Bureau of Prisons - NYM EFTA00059505 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: NSW. Facility: NYM Provider-. MD Unit: HO Note Date: 07/26/2019 08:57 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider. MD TO HIM THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED 2 NIGHTS AGO. New Medication Orders: Medication Order Date Prescriber Order Docusato Sodium Capsule 07/26/2019 08:57 TAKE ONE 10 MG CAP Orally - Two Times a Day x 180 day(s) Indication: Constipation, unspecified Copay Roquirod:No Cosign Required: No TelephoneNerbal Orden No Completed by MD on 07/26/2019 08:58 Gene-Med 0726/2019 0B:58 by MO atteau ol Prisons-NYM Page 1al I EFTA00059506 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Reg 76318.054 Inmate Name: EPSTEIN. JEFFREY EDWARD Sex: i m iSa Failily: NYM Date of Birth: 01/20/1953 Unit: H01 Provid er: MD Note Date: 07/24/2019 16:10 Health Services. Cosign Note - Clinical Encounter Cosign encounter performed at Administrative Notes: Provider: MD ADMINISTRATIVE NOTE 1 MENT REGARDING WHAT HAPPENED TO HIM THE MLP NOTIFIED THE OP LT OF THE INMATE STATE 2 NIGHTS AGO. Copay Required:No Cosign Required: No TelephoneNerbal Order: No Completed by 24/2019 16:12 Page 1 of 1 Bureau of Prisons NYM Generated 07/2412019 16:12 by EFTA00059507 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Reg 76318-054 Inmate Nemo: EPSTEIN. JEFFREY EDWARD NYM Date of Birth: 01/20/1953 Sex: H01 Provider: =NM= MD Unit: Note Date: 07/24/2019 16:10 ed at Health Services. Cosign Note - Clinical Encounter Cosign encounter perform Administrative Notes: Provider: MD ADMINISTRATIVE NOTE 1 HIM MENT REGARDING WHAT HAPPENED TO THE MLP NOTIFIED THE OP LT OF THE INMATE STATE 2 NIGHTS AGO. Copay Required:No Cosign Required: No Te lephoneNer ba I Order: Completed by 24/2019 16:12 Page 1 of 1 MD Bureau of Prisons - NYM Generated 07/24/2019 1612 by EFTA00059508 Bureau of Prisons Health Services See Amendment Reg #: 76318-054 EDWARD Inmate Name: EPSTEIN, JEFFREY M Race: WHITE 01/20/1953 Sex: NYM Date of Birth: Facility: Encounte r Date : 07/26/2019 08:57 MD on 07/26/2019 08:58. Amendment made to this note bat SHOW Or - YM em.N EFTA00059509 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD i s ailla Facility: NYM Date of Birth: 01/20/1953 Sex: Provider: MD Unit: H01 Note Date: 07/24/2019 15:10 med at Health Services. Admin Note - General Administrative Note encounter perfor Administrative Notes: Provider: MD ADMINISTRATIVE NOTE 1 EVALUATION. HE REFUSED. REFUSAL FORM PATIENT WAS OFFERED TO HAVE AN OPTOMETRIST SIGNED. Copay Required:No Cosign Required: No TelephoneNerbal Order No Completed by MD on 07/24/2019 15:17 Bureau of Prisons • NYM Pago 1 of 1 Generated 07/202019 15:17 by MD EFTA00059510 Bureau of Prisons Health Services Clinical Encounter Reg 1$: 76318.054 Inmate Name: EPSTEIN, JEFFREY EDWARD Sex: • WHITE Facility: NYM Date of Birth: 01/20/1953 Provider. MLP Unit: H01 Encounter Date: 07/24/2019 13:08 Mid Level Provider - Follow up Visit encounter performed at Receiving & Discharge. SUBJECTIVE: COMPLAINT 1 Provider: ME MLP Chief Complaint: Other Problem had to do with Subjective: I still do not want to talk about. But, between you and me. I think my room mate what happened to me. Do not ask me. I am not going to say anything. Pain: No OBJECTIVE: Temperature: Data Time Fahrenheit Celsius Location Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral a MLP Pulse: Ilmo Rate Per Minute Location Rhythm Provider Data 07/24/2019 13:12 83 Via Machine Regular INN MLP Blood Pressure: Data II= Value Location Position Cuff Size a Right Arm Sitting Adult-regular MIMI MLP 07/24/2019 13:12 NYM 132/89 SaO2: Rate Time Value(%) Al[ Provider 07/24/2919 13:12 NYM 96 Room Air 1.11 MLP Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Appears in Pain Fxam Comments Follow up evaluation done for inmate Epstein. He does not look in any pain or distress. do s not complaint He still has the erythema around his neck. Central part of this erythema has some abrasion. Patient how the skin Injury on his neck gipped. he of any respiratory problem or distress. He still does not want to explain 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: ?ALP Bureau of NYM Page 1of 2 Genoraux107/24/2019 13:24 by EFTA00059511 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD WHITE Facility: NYM Sex: Date of Birth: 01/20/1953 . MLP Unit 1101 Provider: Encounter Date: 07124/2019 13:08 Follow-up at Sick Call as Needed Patient Education Topics: Outcome Pate Initiated Format Handout/Topic Verbalizes 07/24/2019 Counseling Access to Care Understanding Verbalizes 07/24/2019 Counseling Preventive Health Understanding Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Completed by MLP on 07/24/2019 13:24 Requested to be cosigned by MD. page. Cosign documentation will be displayed on the following Eluroau of Prisons • NYM Piga 2 d 2 Gcnorulod 07/24/2019 13:24 by MLP EFTA00059512 Bureau of Prisons Health Services Cosign/Review Reg 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Race: WHITE Date of Birth: 01/20/1953 Encounter Date: 07/24/2019 13:08 Sex: Provider: imm MLP Facility: NYM Cosigned with New Encounter Note by D on 07/24/2019 16:10. Bureau of Prisons • NYM EFTA00059513 Bureau of Prisons Health Services Clinical Encounter Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Facility: NYM Sex: WHITE Date of Birth: 01/20/1953 Unit: H01 Encounter Date: 07/23/2019 06:20 Provider. . MLP Injury Assessment • Non-work related encounter performed at Health Services. SUBJECTIVE: INJURY 1 Provider: MM. 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 (Bo 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: Date fine Fahrenheit Celsius Location Provider 07/23/2019 06:30 NYM 97.5 36.4 Oral EMI MLP Pulse: Rate Per Minute Location Rhythm provider Pete Tune 07/23/2019 06:30 92 Via Machine Regular . MLP Respirations: Pitt Time Rate Per Minute Provider 07/23/2019 06:30 NYM 16 . MLP Blood Pressure: Data. Tina Vailll Location Position Cuff Size Erraid_er 07/23/2019 06:30 NYM 140/85 Right Arm Sitting Adult-regular . MLP SaO2: Data Time Value(%) Air 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, MLP Bureau of Prisons • NYM Page 1 of 2 Generated 07/23/2019 09.05 by EFTA00059514 Reg #: 76318-054 RD Inmate Name: EPSTEIN, JEFFREY EDWA lair WHITE Facility: NYM 1953 Sex: Date of Birth: 01/20/ MLP Unit: H01 Provid er. Encounter Date: 07/23/201906:20 Exam: Acutely III Pulmonary Auscultation s Bilaterally Yes: Clear to Auscultation, Vesicular Breath Sound No: Crackles, Rhonchi, Wheezing Fxam Comments Inmate for injury report as requested by Operational Lt. Alleges, that he does not is ambul atory, oriente d x 3. In not apparent distress, smiling during this clinical encounter. He his neck. Responded: I don't know°. know what happened. Can not explain the marks on on his neck. He does not want to talk of the events leading to the marks He does not look in any distress or pain. wide, sparing Reaching 2/3 of the neck circumference, 2 inch Has an circular line of erythema at the base of the neck. . in the front with marks of friction the back of the neck. Has one section of this erythema omas, no lacera tions, no tenderness. Patient moving his neck without any No inflammation, no deformities, no hemat respiratory problem. restriction. Denies having any pain or discomfort. Denies any knee about 2cm In dlame ler(mil d). Has another small erythema on left inmate Epstei n was found in his cell with a rope around his neck a sitting on the As per Information from custody staff floor. Inmate is currently placed on suicide watch. ASSESSMENT: Injury, unspecified, T1490 - Current - R/O self Mflicted injuries. PLAN: Disposition: Folow-up at Sick Call as Needed Placed on Suicide Watch Fellow-up in 2-4 Hours Other: For follow up with psychology service. Patient Education Topics: Outcome naltunitlatad Emma Handout/Topic Verbalizes 07/23/2019 Counseling Access to Care flia• Understanding Verbalizes 07/23/2019 Counseling Plan of Care Understanding Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Comp!eted by MLP on 07/23/2019 09:05 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Bureau of Prisons • NYM Page2o1 2 Genurate0 07/23/2019 09:05 by MU' EFTA00059515 Bureau of Prisons Health Services Cosign/Review Reg tt: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Race: WHITE Date of Birth: Encounter Date: 01/20/1953 07/23/ 2019 06:20 Sex: Provider. MIMI MLP Facility: NYM Cosigned by 1D on 07/2312019 15:44. Bureau diMars NYM EFTA00059516 Bureau of Prisons Health Services Clinical Encounter Reg 1$: 76318 54 Inmate Name: EPSTEIN, JEFFREY EDWARD Sex: M Race: WHITE Facility: NYM Date of Birth: 01/20/1953 Provider: MD Unit: Z05 Encounter Date: 07114/2019 17:36 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 TRI L WAS 800 , NOW 431. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERID MEDS DUE TO THEIR GI SIDE EFFECTS. HX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CP MACHINE. STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTE STATES THE FBI LOKELY HAS L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES. SURGICAL HX: NONE MENTAL HEALTH HX: NONE Pain: Yes Pain Assessment Dato: 07/12/2019 13:25 Location: Back-Middle Quality of Pain: Shooting Pain Scale: 5 Intervention: MEDROL DOSE PACK Trauma Date/Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbatin g Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: Soon for clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid Added to clinIc(s): OrthopecIldRheumatology, 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 Mn Bureau of Prisons • NYM Page 1d 3 EFTA00059517 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Sox: M Race: WHITE Facility: NYM Date of Birth: 01/20/1953 Z05 Provider: MD Unit: Encounter Date: 07/14/2019 17:36 Exam: Eyes General Yes: PERRLA, Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2 No: MIRJG Abdomen Auscultation Yes: Norma-Active Bowel Sounds Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back Yes: Tenderness Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam ASSESSMENT: Constipation, unspecified, K5900 - Current Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: Medication Order Date Prescriber Order Siff Omega 3 ( Vascepa) 1 GM Capsule 07/14/2019 17:36 TAKE 2 CAPS (cagy - Two Times a Day x 1 dey(s)— TAKE WITH FO . Indication: Hyperlipidemia, unspecified New Laboratory Requests: Retails Frequen Rue Pate Lab Tests-H-Hemoglobin A1C One Time 10/10/2019 00:00 Routine Lab Tests-L-Lipid Profile Additional Information: MO Buroau of Pelson NYM P696242( 3 Genera:ad 07/14/2019 18:11 by EFTA00059518 Reg N: 76318-0fr4 Inmate Name: EPSTEIN, JEFFREY EDWARD E Facility: NYM Sex: Date of Birth: 01/20/1953 MD Unit: Z05 ' Provider: Encounter Date: 07/14/2019 17:36 FASTING. Routine One Time 08/08/2019 00:00 Lab Tests-H-Hep B surface Ab Lab Tests-H-Hep B surface Ag Lab Tests-H-Hep C Ab Lab Tests-H-Hepatic Profile Schedule: Activity Date Scheduled, Scheduled Provider Clinical Encounter 07/24/2019 00:00 Optometrist 66 YR OLD MALE FOR ROUTINE SCREENING. Chronic Care Visit 01/07/2020 00:00 Mid-Level Provider 6 MONTH F/U. Chronic Care Visit 07/01/2020 00:00 Physician 01 Other: PENDING EKG AND FOBT. CXR WAS REFUSED. Patient Education Topics: provider 1211101111 Date Initiated formal flardougTopig Beaudouin, Robe Verbalizes 07/14/2019 Counseling Diagnosis Understanding Copay Required:No Cosign Required: No TeiephoneNerbal Order: No Completed by MD on 07/14/2019 18:11 MD Bureau of Prisons - NYM P0003013 Generated 07/1O2019 1811 by EFTA00059519 CDFRM BP-S358.060 MEDICAL TREATMENT REFUSAL SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Fe eral Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental 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 NYM—NEW YORK MCC Si nature of Wane s Date EFTA00059520 COMM BP-S358.C60 MEDICAL TREATMENT REFUSAL 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 condltion(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: 66 YR OLD MALE WITH NO PMI-IX , REFERRED FOR ROUITNE CXR. The following treatment(s) was/were recommended: CHEST X-RAY • Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible conseque nces and/or complicat ions 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 NYM-NEW YORK MCC Signature of Witness EFTA00059521 CDFI1M BP-5358.060 MEDICAL TREATMENT REFUSAL SEP OS U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2016 Date I, JEFFREY EPSTEIN 76318.054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the folio ving ment: possible consequences and/or complications may result because of my refusal to accept trea INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and f llowing my expressed wishes and directions. MD 7-24-2019 Date Pa nt's Sign i Date Counseled by alter NYM--NEW YORK MCC Si nature of VVitnel s Sr Date EFTA00059522 BP-A0618 A&O DENTAL EXAMINATION (Initial Clinical Dental Findings) JUN 16 FEDERAL BUREAU OF PRISONS U.S. DEPARTMENT OF JUSTICE Occlusion: Oral Hygiene: Good Fe CP;TN: 3 2 3 3 2- 3 Mead & Neck / Soft Titarrre 1 2 3 4 5 8 7 8 9 1011 1213 14. 15 16 • O 32 31 30 29 28 27 26 25 24 23 22 21 20 19 - 18 I? 4 Classification: D; It CLIC. Pain Scale: Conlin 40 eotl i Ci 4tV411 , in nica Dental Prostheses at Intake: Yes No Typo: CC.Ci2 SS, on Di,Seili-e- Ase: 14" --.1e C"'"- Ael at CarzysliA c 0.109-P-14 Condition: cn A&O encounter) Infra-oral Photos Taken Radiographs Taken: (Document findings Yes Yes No • 0 Yes: I No: Instructed hcnv to obtan urgent and non-urgent dental care: None: Non-urgent Urgent Refierred to Sick Cat Treatment Priorities: non-urgent Prophylaxis authorized: Yes I No Radiographs authorized; PM: (Approval va-xl 18 months from examination date)I BWs Panorex Papnt Name: Den s-can 1 -3 --e_c-R•fe DDSs .,:krEteNumber: iInstitution: / Date: signature Blar.k/Stamp: 74,3 is: os-/411 MCC NEW YORK 7-* 2-6 —/ 9. et en cer IDS. MCC New York Replaces BP-A0B18 olJUN 10 PDF Prescribed by P6403 EFTA00059523 BP4,0618 A&O DENTAL EXAMINATION JUN 18 (Initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS U.S. DEPARTMENT OF JUSTICE Ocduslon: Oral Hygiene: Good ■ CPITN: 3 Head & Neck Soft Tissue: 2- 3 1 2 3 4 6 8 7 $ 0 1011 12 13 14 15 18 t9 32 31 30 29 25 27 2825 21 23 22 21 20 10. 18 17 Cla ificatLOn: (AL fy Nt I CL- -T- F: Li Pain Scale: /10 Dental Prostheses et Intake: rnrantl Crcri 4 O Z it (tercV ' 4, 1 N2511•1 Yes No Typo: it 02 SS / on C4r) SeiV-e- Age: 1.4 -r C,...-‘,Aci o/ Cityyld.inc 0 .19Se-file4 Codition: Infra-oral Photos Taken: Radiographs Taken: (Document findings on AM) encounter) Yes Yes 0 9 . Instructed how to cbtaLn urgent and non-urgent dental care: Yes: I No: Treatment PrioriSes: None: Nen-urgent Urgent Referred to Sick Cail: non-urgent Radiographs authorized: • Prophylaxis authortzed: Yes I No PM: (Approval valid 10 months from examination date) BWs Panore:c Palient Narrar. , D " nature: C,..-isti rskin , -3-cc-R--e_v £ ELI- r Hanby: Institution: / Date: I>Ds Signature Block/Stamp: -76 3 I Se:- os-m MCC NEW YORK 7- 26 -1 9. et en a 9 DS ter MCC New York PCF Presented by P8400 Replaces BP-A0618 of -UN 10 EFTA00059524 COFFIM SP-S358.060 MEDICAL TREATMENT REFUSAL SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Fe eral Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental co dition, and release the Bureau of Prisons and its employees from any and all liability for respecting and f (lowing my expressed wishes and directions. MD 7-24-2019 Counseled by Dale Date NYM-NEW YORK MCC Si nature of VVitne Dale EFTA00059525 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 Unit E06-547U Received 07/10/2019 10:44 DOB 01/20/1953 Provider WI= MD Reported 07/10/2019 14:46 Sex M LIS ID 188191004 HIV HIV 1/2 Negative Negative Screening test - See confirmatory teeing (or Reactive results FLAG LEGEND L=Low LI=Low Critical H=High HI=High Critical A=Abnormal Al =Abnormal Critical Page 3 of 3 EFTA00059526 Bureau of Prisons Health Services Cosign/Review Reg #: 76118-054 Inmate Name: EPSTEIN, JEFFREY EDWARD 01/20/1953 Sex: M Race: WHITE Date of Birth: Provider: Lab Result Receive Facility: NYM Encounter Date: 07/10/2019 16:58 Cosigned by MD on 07/14/2019 18:12. Bureau of Prisons - NYM EFTA00059527 CDFRM BP-S358.C,50 MEDICAL TREATMENT REFUSAL 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 tho following possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse condition, and recommended treatment I hereby assume all responsibility for my physical and/or mental release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. MD 7-242019 Date Date Counseled by ark SI nature of VVitne s Date ~ i NYM—NEW YORK MCC EFTA00059528 SP-A0618 A&O DENTAL EXAMINATION JUN 18 (Initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS U.S. DEPARTMENT OF JUSTICE Occlusion: OOr • Oral Hygiene: Good Fair I / Craw: 3. 3 3 Head 8 Neck / Soft Tissue: 2- 9 1 2 3 4 6 6 7 8 9 1011 1213 14. 15 IC 2 CC 32 31 30 29 23 27 2625 2123 22 21 20 W. 18 17 Classification: D: CL_ en- It* rgt F: Pain Scale: /1G Dental Pros-theses at Mai= Cs:Ina/ p ...67 a ii,15 aka Yes TYPo: Age: cccession Di, / a -1° c Seil.) -12- C.--s. i tel ed-Cco-OcLiA5 0 109-/484 Condition: Intra-cind Photos Taken: Radiographs Taken: (Document frndings on A&O encounter) Yes Yes No 0 Instructed how to obtain urgent and non-urgent dental care: Yes: I No: Treatment Pitontes: None: Non-urgent Urgent Referred to Sick Call: non-urgent . Prophylaxis auUtortzect Yes I No Radiographs authorized: PAs• (Approval var 18 months from examination date) EPNs: Panorox t Nan= i Dentist Si nature: iPc it 9 4t, lisznben n -37 6 7‘ 3 IS= OS-1/4\ MCC NEW YORK 1-rite_ Institution: E. Date: 7- 06 -19. 1,3" Signature Block/Stamp: DDS. eniet IJenta101ticer MCC New York PDF Peescrtbed by P8400 MOWN 8P-Men NUN 10 EFTA00059529 SP-S358.060 MEDICAL TREATMENT REFUSAL C0FRM 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 and recommended treatment I hereby assume all responsibility for my physical and/or mental condition, release the Bureau of Prisons and its employees from any and all liability for respecting and • wing my expressed wishes and directions. 1 MD 7-24-2019 Counseled by Dale a is Sig NYM-NEW YORK MCC Si nature of Wan s Date EFTA00059530 CDFRM BP-S358.CE0 MEDICAL TREATMENT REFUSAL SEP 05 FEDERAL BUREAU OF PRISONS U.S. DEPARTMENT OF JUSTICE 7-10-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: 66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR. The following treatments) was/were recommended: CHEST X-RAY Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: WORSENING THE CONDITION IF THERE IS ANY FINDINGS I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and Its employees from any and all liability for respecting and following my expressed wishes and directions. X-RAY 7-10-2019 Date Patten Signature t Date Counseled by NYM—NEW YORK MCC Signature of Witness Date EFTA00059531 A&O DENTAL EXAMINATION • • • SP-A0618 JUN 18 (Initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Occlusion: Oral Hygiene: Good Fair Zoo r CPITht 3 3 Head & Neck / Soft Tissue: 3 2- 3 1 2 3 4 5 8 7 8 0 1011 1213 14. 15 16 (2 32 31 30 29 28 27 2825 2423 22 21 20 18. 18 17 21 ClassL5cation: O: C7 r 11A lv CL_rr P L I Pain Scale: /10. Dental Prostheses at Intake: Comml rim .k r_15,1Ai ni ) No Yes r-toz SS / On 017Sal• Le^ • Type: fi e" Calditicn: , 0 -0-- 14.. C/o-OAJA1 O---‘, cet or plosefik-4 InUa-oral Photos Taken: Radiographs Taken: (Document findings on ASO encounter) I Yes Yes 0 No . Instructed hcriv to ahem' urgent and non-ergent dental care: Yes: I No: Treatment Haan: None: Nco-tegent Urgent Referred to Sick Cat non-urgent . - Prophylaxis authorized Yes i No Radiographs authorized; PAs: (Approval valid 18 months from examination date) BW5: Pan ca Pa ' Name: Dentist SI lure: n 1, trcc-civey E. 1>Ds 4? S —C; Nurnbec '7C 3 IC= OS1/4\ institution: t MCC NEW YORK Date: 7— 7 6 --/ 9 • Ignature Slock/StamP: DS. te entl lcer MCC New York PDF Presaibed by P8400 • Replaces BP•Atal 8 of JUN 10 EFTA00059532 Bureau of Prisons Health Services Clinical Encounter Reg #: 76318-0 Inmate Name: EPSTEIN, JEFFREY EDWARD Facility: NYM Sex: M Race: WHITE Date of Birth: 01/20/1953 Unit: Z04 Provider. RN Encounter Date: 08/10/2019 07:25 Unit. Emergency Code - Resuscitation Event encounter performed at Special Housing SUBJECTIVE: Emergency Note Provider: RN Team Members: Provider Balt RN Team/Code Leader Code Events: Value, Date 1-Yea 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 08/10/2019 07:08 ET Tube 7.5 24CM to L Lip line Placed by Paramedics 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 o the floor of his cell unresponsive with CPR in progress by correctional officers, Inmate was Cold, with circumferential B ising around the neck and posterior mottling, Pupils Fixed and dilated, No Palpable pulses. Call place for EMS, CPR timed, AED Placed No shock advised, CPR Continued, inmate transported to HSU treatment room with CPR in pro ress, 18g hep lock to L AC, O2 15 Lt ViA BVM, Pulse Check NO SHOCK advised. EMS and Paramedics arrived 0656, Pla ed on cardiac monitor asystole Resumed CPR, Inmate was intubated by Medics, 3 Rounds of Epinephrine administere d. Pulse Check asystole, Inmate was transported to Local ER with CPR in progress. OBJECTIVE: Exam: General Appearance Yes: Unconscious Generated 69110/2019 08:10 by RN Bureau of Prisons - NYM Pap 1of 2 EFTA00059533 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: ISSIII I TE Facility: NYM Provider: RN Unit: Z04 Encounter Date: 08110/2019 07:25 Exam: ASSESSMENT: Cardiac Arrest PLAN: New Consultation Requests: Translator Language Consultation/Procedure larRethate Scheduled Target Date Priority 08/10/2019 08/10/2019 Emergent No Emergency Room Subtype: AMBULANCE Reason for Request: Cardiac arrest with CPR in progress Copay Required:No Cosign Required: Yes TelophoneNerbal Order: No Completed b RN on 08/10/2019 08:10 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. RN Bureau of Prisons - NYM Pepe 2 of 2 Generated 08110/2018 08:10 by EFTA00059534 Bureau of Prisons Health Services Clinical Encounter Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Sex: Facility: NYM Date of Birth: 01/20/1953 der Provider. Unit: Z01 Encounter Date: 07/30/2019 15:58 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: AD 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 MAC INE. I INFORME DHIM THAT WE RECEIVED HIS CPAP MACHINE AND IT WILL BE GIVE TO HIM TONIGHT.. HE REPORT OTHER NON-MEDICAL ISSUES. STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Seen far clinic(s): Pulmonary/Respiratory, Orthopedlc/Rheumatology, Endocrine/Lipid OBJECTIVE: Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely III Nutrition No: Appears Obese Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR), Normal Si and S2 No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neurologic Generated 07130/2019 16:12 a MD Bwoau of Prisons • NYM Poop1of 2 EFTA00059535 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Facility: NYM Date of Birth: 01/20/1953 MD Unit ZO1 Encounter Date: 07(30/2019 15:58 Sex: er: Provid Exam: Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: t Body mass index (BMI) 27.0-27.9, adult, 26827 - Curren Constipation, unspecified, K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hypedipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, R7303 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: Prescriber Order Medication Order Data Ert! SLIDING SCALE INsulin REG - Human 07/30/2019 15:58 Subcutaneously each morning x 7 day(s) Pill Line Only Indication: Prediabetes Discontinued Medication Orders: Order Date Prescriber Order Medication 07/30/2019 15:58 Inject regular insulin 122148-NYM Insulin Rog (10 ML) 100 UNITS/ML In] subcuteneousisi per sliding scale: twice daily "VT line*" for 7 days Discontinue Type: When Pharmacy Processes Discontinue Reason:new artier written Indication: Copay Required: No Cosign Required: No TelephoneNerbal Order: No Completed by MD on 07/30/2019 16:12 Pegs 2 2 MD Bureau cr Prisons • NYM Generated 07/30/2019 16:12 by EFTA00059536 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg ll: 76318-054 Date of Birth: 01/20/1953 Sex: TE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: tvID Unit: 201 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: MD Chief Complaint: Other Problem Subjective: PATIENT S REFERRED BY THE WARDEN FOR EVALUATION. PATIEN E RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO E RRR S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STAT BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. HE DENT ,6 SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING qp3, AL. OWING. HE REPORTST 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 SLEEW5f AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HEREt§ CE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE R Et D HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-ME UES. STATES HE FEELS OTHERWIS E Pain: Not Applicable Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology. Respiratory OBJECTIVE: Pulse: Time Rate Per Minute Location Provider nate 94 MD 07/30/2019 13:02 88 Via Machine MD 07/30/2019 09:40 07/30/2019 09:30 87 Via Machine Respirations: Date Time Rate Per Minute Provider 07/30/2019 09:30 NYM 12 MD Blood Pressure: Date Time Value Location • osition Cuff Size Ov' St I NYM 114/84 Loft Arm Standing MD 07/30/2019 13:02 Right Arm Standing MD 07/30/2019 09:40 NYM 125/60 Loft Arm Sitting MD 07/30/2019 09:30 NYM 108/86 SaO2: aat Time Valuef%1 Air Provider 09:30 NYM 98 Room Air MD 07/30/2019 Weight: 2119 Time LL s gs Waist Circum. Provider Bureau of Prisons • NYM Page 1 of 3 Generated 07/3012019 14;05 by MD EFTA00059537 Reg ri: 76318.054 Inmate Name: EPSTEIN, JEFFREY EDWARD Race: WHITE Facility: NYM Sex: M Date of Birth: 01/20/1953 MD Unit: Z01 Provider: Encounter Date: 07/30/2019 11:12 Date Time Lla Kg Waist circum Provider 88.1 MD 07/30/2019 09:30 NYM 194.2 Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 retic. Writhing in Pain, Pale, Pallor, Cyanotic, Diapho No: Appears Distre ed. Dyspneic, Appears in Pain, Disheveled, Unke Acutely III Nutrition No: Appears O Pulmo nary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR 1 and S2 No: M/R/G Muscu loskel etal Tibia / Fibula No: Edema Neuro logic 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: Order Date prescriber Order Rx Medication Page 2 of 3 MO Bureau of Prisons • NYM Generated 07/30/2019 14:05 by EFTA00059538 Reg It: 76318.054 Inmate Name: EPSTEIN, JEFFREY EDWARD Sex: TE Facility: NYM Date of Birth: 01/20/1953 201 Provider: t MD Unit: Encounter Date: 07/30/2019 11:12 Now Medication Orders: Order Date Prescriber Order 8,31 Medication Magnesium Hydroxide Susp cone 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: Prediabeles Renew Medication Orders: Medication. Order Date prescriber Order Exit 121836-NYM methylPRD o ne 4 MG Tab ( 21 count 07/30/2019 11:12 Take the tablet by mouth as Pack) directed x 6 day(s) Indication: NJ Thia and neuritis, unspecified New Laboratory Requests: Details Frequency Due Date Priority. no Time 08/01/201900:00 Routine Lab Tests - Short List-General-CBC w/diff Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short List-General•Comprehonsiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic New Radiology Request Orders: Details Frequency, Due Date Priority. General Radiology-S pine / 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: PrQvider Clu_tcocae Date Initiaten Format Handout/Tot& Counseling Access to Care Beaudo Verbalizes 07/30/2019 Understanding 07/30/2019 Counseling Plan of Care Verbalizes Understanding Copay Required:No Cosign Required: No TelephoneNerbal Order: No Completed by - MD on 07/30/2019 14:05 MD Bureau of Prisons • NYM Page 301 3 Generated 07/30/2019 14:05 by EFTA00059539 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: Facility: NYM MD Unit: ZO1 Encounter Date: 07/30/2019 11:12 Provider: Chronic Care - Chronic Care Clinic encounter performed al Health Services. SUBJECTIVE: COMPLAINT 1 Provider: MD Chief Complaint: Other Problem Subjective: PATIENT s e AS REFERRED BY THE WARDEN FOR EVALUATION. PATIEN rigEP,ORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO AE 11:InTS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STATES) BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. HE DENI SIDED WEAKNESS, DIPLOPIA. FACIAL DROOP, DIFFICULTY SPEAKING ALLOWING. HE REPORT IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. HE REPORTS H DNEY STONES. FIX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEE_P_Ap AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HER CE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE R Et1LED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-ME UES. STATES HE FEELS OTHERWISE Pain: Not Applicable Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rhoumatology, espiratory 7) OBJECTIVE: Pulse: Dag Time Rate Per Minute Location Provider 94 MD 07/30/2019 13:02 88 Via Machine MD 07/30/2019 09:40 87 Via Machine MD 07/30/2019 09:30 Respirations: Date Time Rate Per Minute. Provider 07/30/2019 09:30 NYM 12 MD Blood Pressure: value Location Position Cuff Size Provider 07/30/2019 13:02 NYM 114/84 Left Arm Standing Beaudouin. Robert MD Right Arm Standing MD 07/30/2019 09:40 NYM 125/60 07/30/2019 09:30 NYM 108/86 Left Arm Silting Beaudouin. Robert MD SaO2: Qata nom Value170). A.it Provider 07/30/2019 09:30 NYM 98 Room Air MD Weight: Rate Time Lk Ka Waist cirsam Provisisi MD Bureau of Prisons • NYM Page 1 of 3 Generated 07/30/2019 14:05 by EFTA00059540 Reg ti: 76318.054 Inmate Name: EPSTEIN, JEFFREY EDWARD Sex: l i aise Facility: NYM Date of Birth: 01/20/1953 Z01 Provider: MD Unit: Encounter Date: 07/30/2019 11:12 !Tats Time .K.9 Waist Circum Provider 09:30 NYM 194.2 88.1 MD 07/30/2019 Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distre ed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unke cutely III Nutrition No: Appears Ott Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular viz?1 ,11 Auscultation Yes: Regular Rate and Rhythm (RRR le5and S2 No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neurolog lc 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, 64730 - Current PLAN: New Medication Orders: Medication Order Date Proscriber Order MD Bureau of Prisons - NYM Page 2 or 3 Generated 07130/2019 14:05 by EFTA00059541 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/30/2019 11:12 Sex: Provider: is... MD Reg 76318.054 Facility: NYM Unit: Z01 Now Medication Orders: Order Date Prescriber Order !WI NI • dication 07/30/2019 11:12 10 CC Orally - Two Times a Magnesium Hydroxide Susp cone 800 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: Order Dale, Prescriber Order Exit Medication methylPR o ne 4 MG Tab ( 21 count 07/30/2019 11:12 Take the tablet by mouth as 121836-NYM Pack) directed x 6 day(s) Indication: iTh 1tt, is and neuritis, unspecified New Laboratory Requests: V Frequency Due Date Priority Details - Short List-Genera l-CBC w diff Time 08/01/2019 00:00 Routine Lab Tests Lab Tests-P-PSA , Total Lab Tests-U-Uric Add Lab Tests - Short List-General-Comprehensiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic New Radiology Request Orders: Frequency Due Date Priority Details 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 vidir atitcomq 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 MD on 07/30/2019 14:05 MO Bureau of Prisons • NYM Page 3 of 3 Generated 07/30/2019 14:05 by EFTA00059542 Bureau of Prisons Health Services See Amendment Reg #: 76318-054 Irmate Name: EPSTEIN, JEFFREY EDWARD Race: WHITE 01/20/1953 Sex: M Date of Birth: Facility: NYM Encounter Date: 07/30/2019 15:58 Amendment made to this noto by MD on 07/30/2019 16:12. Bun= of Prisons - NYM EFTA00059543