Bureau of Prisons

Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Race: WHITE Encounter Date: 07/12/2019 13:10 Provider: Reg SI: 76318-054 Facility: NYM Unit: Z05 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDO/LIPID Subjective: 66 YR OL HITE MALE WITH FIX 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. it HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE : Y HAS L4 - LS 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, Pate. Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt. Acutely 111 Nutrition No: Appears Obese Generated 07/7212019 14.20 by Bureau of Prisons • NYM Page I of 3 CONFIDENTIAL SDNY_00009419 EFTA00033825 Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Dale: 07/12/2019 13:10 Provider M Race: WHITE Reg #: 76318-054 Facility: NYM Unit: Z05 Exam: Eyes General Yes: PERRLA, Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal S1 and S2 No: M/R/G Abdomen Auscultation Yes: Normo-Active B Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back Yes: Tenderness ithi Neurologic Cranial Nerves (CN) Yes: W ASSESSMENT: Constipation, unspecified, K5900 - Current 4740.1)0Motor System-Generaln Normal Limits Yes: Normal Exam Hyperlipidemia, unspecified, E785 - Current Low back pain. M545 - Current Neuralgia and neuritis, unspecified, M792 - Current >e, Sleep apnea, G4730 - Current PLAN: New Medication Orders: Rx# Medication QrtesEpa Magnesium Hydroxide Susp 07/12/2019 13:10 Indication: Constipation, unspecified MethyiPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 Pack 21 tab) Indication: Neuralgia and neuritis. unspecified Disposition: Generated 07/122019 14:20 by Prescriber Order" 30 CC Orally - Two Times a Day PRN x 2 day(s) AS DIRECTED Orally - daily x 6 day(s) Bureau of Prisons - NYM Page 2 of 3 CONFIDENTIAL SDNY_00009420 EFTA00033826 Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/12/2019 13:10 Provider: I Reg #: 76318-054 Facility: NYM Unit: Z05 Follow-up at Sick Call as Needed Other: WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP. Patient Education Topics: Pate Initiates'. Format Han ~UTop! 07/12/2019 Counseling Diagnosis Copay Required: No Cosign Required: No TelephoneNerbal Order: Completed by Beaudouin. n 07/12/2019 14:20 Generated 07/12/2019 14 20 by Provider Outcome Verbalizes Understanding Bureau of Prisons NYM Page 3 of 3 CONFIDENTIAL SDNY 00009421 EFTA00033827 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN. JEFFREY EDWARD Reg tit: 76318.054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: Unit: Z05 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDO/LIPID Subjective: 66 YR OL HITE MALE WITH HX OF HYPERT; CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS • EIR GI SIDE EFFECTS. HX OF O 4 UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. -I, 1-Nr* HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE a Y HAS L4 - L5 SEVERE SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMI SURGICAL FIX: NONE MENTAL HEALTH FIX: 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 07112,2019 14 20 by Bureau of Prisons - NYM Page 1 of 3 CONFIDENTIAL SDNY 00009422 EFTA00033828 Inmate Name: EPSTEIN, JEFFREY EDWARD Dale of Birth: 01/20/1953 Sex: Encounter Date: 07/12/2019 13:10 Provider M Race: WHITE Reg #: 76318-054 Facility: NYM Unit: 205 Exam: Eyes General Yes: PERRLA, Exlraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal S1 and S2 No: WR/G Abdomen Auscultation Yes: Normo-Active B 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: Rx# Medication Magnesium Hydroxide Susp Indication: Constipation, unspecified MethyIPREDNISolone Tab 4 MG ( Dose Pack 21 tab) Indication: Neuralgia and neuritis, unspecified Disposition: Corer:nod 01:17,2019 1420 by Order Date 07/12/2019 13:10 07/12/2019 13:10 Bureau of Prisons - NYM aescriber Order 30 CC Orally - Two Times a Day PRN x 2 day(s) AS DIRECTED Orally - daily x 6 day(s) Page 2 of 3 CONFIDENTIAL SDNY 00009423 EFTA00033829 Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/12/2019 13:10 Reg #: 76318.054 Sex: M Race: WHITE Facility: NYM Provider: El 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/Tonic 07/12/2019 Counseling Diagnosis Copay Required: No TelephoneNerbal Order: Cornpteled CI Generated 07/12/2019 14 20 by Cosign Required: No n 07/12/2019 14:20 Bureau of Prisons NYM Provider Outcome Verbalizes Understanding Page 3 of 3 CONFIDENTIAL SDNY_00 009424 EFTA00033830 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/14/2019 17:36 Facility: NYM Amendment made to this note by on 07114/2019 18:11. &mftwoflhiumis.NYM CONFIDENTIAL SDNY_00009425 EFTA00033831 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: Date of Birth: Note Date: EPSTEIN, JEFFREY EDWARD 01/20/1953 Sex: 07/12/2019 09:06 Provider: Reg #: Facility: Unit: 76318-054 NYM 205 Admin Note - Orders encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: PATIENT REQUESTED TO HAVE A COLACE RX , INSTEAD OF TEH BISACODYL FOR CONSTIPATION. New Medication Orders: B.24 Medication Order Date Docusate Sodium Capsule 07/12/2019 09:06 Indication: Constipation, unspecified Discontinued Medication Orders: Bit# Medication. Order Data 121757-NYM Bisacodyl E.C. 5 MG TAB 07/12/2019 09:06 Discontinue Type: When Pharmacy Processes Discontinue Reason:discontinue Indication: Copay Required: No TelephoneNerbal Order: No Completed by Cosign Required: No on 07/12/2019 09:10 Generated 07/12/2019 09:10 by Bureau of Prisons • NYM Prescriber Order TAKE ONE 100 MG CAP Orally - Two Times a Day x 30 day(s) prescriber Order Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10 days Paget& 1 CONFIDENTIAL SONY 00009426 EFTA00033832 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Facility: NYM Note Date: 07/07/2019 00:17 Provider: Sex: Unit: E06 Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MED CL:1 NO CCC APPT. Discontinued Laboratory Requests: Details Frequency Due Date Priority Lab Tests-H-Hemoglobin A1C One Time 08/05/2019 00:00 Routine Lab Tests-C-CBC w/diff Lab Tests-L-Lipid Profile Lab Tests-C-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Rellex to Microscopic Additional Information: 66 y/o male, elevated BP Labs requested to be reviewed by: New Laboratory Requests: Details Freauency DUG Date Priority Chronic Care Clinics-Diabetic-CBC w/diff One Time 07/25/2019 00:00 Routine Chronic Care Clinics-Diabetic-Lipid Profile Chronic Care Clinics-Diabetic-Hemoglobin A1C Lab Tests-H-HIV 1/2 Lab Tests-R-RPR Chronic Care Clinics-Diabetic-Comprehensive Metabolic Profile (CMP) New Radiology Request Orders: Details Frequency End Date Due Date Priority General Radiology -Chest-2 Views One Time 07/25/2019 Routine Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR. Copay Required: No TelephoneNerbal Order: No Completed by Generated 07/07/2019 00:30 by Cosign Required: No on 07/07/2019 00:30 Bureau of Prisons - NYM Page 1 of 1 CONFIDENTIAL SDNY_00009427 EFTA00033833 Bureau of Prisons Health Services History & Physical Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/09/2019 12:35 Sex: M Race: WHITE Provider: Reg #: Facility: Unit: 76318-054 NYM H01 Seizures: Diabetes: Cardiovascular: CVA: Hypertension: Respiratory: Sickle Cell Anemia: Carcinoma/Lymphoma: Allergies: Tuberculosis: Denied Denied Denied Denied Denied Denied Denied Denied Denied Hx of Previous Disease: No Blood-tinged Sputum: No Night Sweats: No Weight Loss: No Fever: No Cough:No Comments: Infectious Disease Risk Factors: IV Drug Use: No IV Drug Use Needles: Sexual Partner IV Drug Use: No Sexual Partner IV Drug Use Needles: Female Sexual Partners (Last 5 Yrs): 10+ Male Sexual Partners (Last 5 Yrs): 0 Condom Use: Sometimes Sexual Contact With HIV+ Individual: No Blood Product Transfusion: No Travel Outside US: Yes Tattoos: No Comments: Born in US High school diploma Banker Traveled to Pans x 3 weeks up until arrest No tattoos Generated 07/09/2019 13:03 by Bureau of Prisons - NYM Page 1 of 13 CONFIDENTIAL SDNY_00009428 EFTA00033834 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/09/2019 12:35 Provider: imilfaHITS Reg #: 76318-054 Facility: NYM Unit: H01 HIV History: When Tested: 2019 Test Result: Negative When Diagnosed AIDS: Last CD4: Comments: Hepatitis: Denied Other Infectious Diseases: Syphilis: No Syphilis Last Treatment: N/A Genital Warts: No Chlamydia: Yes Gonorrhea: No Herpes: No Chicken Pox: Yes Other: No Comments: Chlamydia in 2015, treated Chicken pox in childhood Abuse History: Denied Physical: No Emotional: No Sexual: No Comments: Denies Generated 07/09/2019 13:03 by Bureau of Prisons - NYM Page 2 of 13 CONFIDENTIAL SDNY_00009429 EFTA00033835 Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/09/2019 12:35 Provider: Reg #: 76318-054 Facility: NYM Unit: H01 Mental Health: Level of Consciousness: Alert and Oriented Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Hx of Mental Health Treatment: None Hx of Head Injury: None Current Mental Health Treatment: No Current Mental Health Complaint: No Hx of Loss of Consciousness: No Hx of Hearing Voices: No Past History of Suicide Attempt: No Current Suicide Ideation: No Suicide Prevention Initiated:No Comments: Substance Use History: Denied Current Painful Condition: Denied Other Health Issues: Current Medical Conditions: Other Current Treatments: Pregnant: N/A Dental Condition: Denied Generated 07/09/2019 13:03 by Bureau of Prisons • NYM Page 3 of 13 CONFIDENTIAL SDNY_00009430 EFTA00033836 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/09/2019 12:35 Provider: 1.1../HITS Reg #: 76318-054 Facility: NYM Unit H01 Observations: Draining Skin Lesions: No Signs of Lice: No Signs of Scabies: No Signs of Recent Trauma: No Recent Tattoos: No Needle Marks: No Signs of Rash: No Open Sores: No Wounds: No Body Deformities: No Tremors: No Sweating: No Comments: Generated 07/09/2019 13:03 by Bureau of Prisons - NYM Pardo( 13 CONFIDENTIAL SDNY_00009431 EFTA00033837 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/09/2019 12:35 Provider: Race: WHITE Reg #: 76318-054 Facility: NYM Unit: H01 Immunizations: Hepatitis A and B (TwinRx) Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Measles/Mumps/Rubella Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: Location: Drug Mfg: Lot Number Dosage: Route: Exp Dt: Comments: Smallpox Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: 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 07/09f2019 13:03 by Bureau of Prisons - NYM Page 5 of 13 CONFIDENTIAL SDNY_00009432 EFTA00033838 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 07/09/2019 Sex: • ITE Encounter Date: 07/09/2019 12:35 Provider. Reg #: 76318-054 Facility: NYM Unit: H01 Immunization Date: Provider: Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Varicella Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Temperature: pate Time Fahrenheit Celsius Location provider 07/09/2019 12:49 NYM 97.3 36.3 Oral Pulse: DAM Time Rate Per Minute Location Rhythm Provider 07/09/2019 12:49 82 Via Machine Regular Respirations: Date Time Rate Per Minute Provider 07/09/2019 12:49 NYM 16 Blood Pressure: DAM Time Yarn Location Position Cuff Slut Provider 07/09/2019 12:49 NYM 117/66 Right Arm Sitting Adult-regular SaO2: Data Time Valuee4). Air Provider 07/09/2019 12:49 NYM 97 Room Air Height: DatS lima Inches fa Provider 07/09/2019 12:49 NYM 70.0 177.8 Generated 07,09/2019 13:03 by Bureau of Prisons • NYM Page a of 13 CONFIDENTIAL SDNY_00009433 EFTA00033839 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/09/2019 12:35 Provider: Reg #: 76318-054 Facility: NYM Unit: H01 Date Time inches Cm Provider Weight: Mt Int Lbs. hg Waist Circum. Provider 07/09/2019 12:49 NYM 194.4 88.2 Prosthetic Devices/Equipment: Denied Tobacco Usage: Denied General Social History: Foreign Travel: Born in USA: Yes Country of Birth: USA Patient Education Assessments: Date Ed Yrs Occupation Learns Best By Primary Language Barriers to Education 07/09/2019 12 Banker Speaking/Listening English None Family History - Father: Age at Death: 74 Cause of Death: Diabetes complications Significant Illnesses: Diabetes Heart Disease Comments: Family History - Mother: Age at Death: 81 Cause of Death: Kidney Failure Significant Illnesses: Heart Disease Comments: Family History - Sibling: Number of Siblings: 1 Significant Illnesses: Comments: Past Hospitalization: Reason Location When Acute Appendicitis Mount Sinai Hospital 1990 Complications: None Comments: Head: Normal: Yes Comments: Generated 07/09/2019 13:03 by Bureau of Prisons NYM Page 7 of 13 CONFIDENTIAL SDNY_00009434 EFTA00033840 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race. WHITE Encounter Date: 07/09/2019 12:35 Provider: Reg #: 76318-054 Facility: NYM Unit: H01 Eyes: EOMI: Yes lcterus:No Conjunctival Inflammation: No Pupils PERRLA: Yes Pupil Size Rt: Pupil Size Lt: Pupils Comments: Fundi Vessels Nicking: No Fundi Vessels Discs Flat:Yes Fundi Vessels Discs Sharp Margins: Yes Fundi Vessels Grounds Abnormal: No Eyes Comments: Vision Screen 07/09/2019 12:52 Blindness: With Corrective Distance Vision: OD: 100 OS: 70 OU: OD: Near Vision: OD: OS: OU: OD: lshihara 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 OS OS: OU: OU: Bureau of Prisons • NYM Page 8 of 13 CONFIDENTIAL SDNY_00009435 EFTA00033841 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/09/201912:35 Provider: Reg #: 76318-054 Facility: NYM Unit: H01 Mouth Lesions:No Oral/Buccal Mucosa:Yes Gums Normal: Yes Tonsils Present:Yes Tonsils Normal: Yes Pharynx: Normal Color Teeth Poor Dentition: No Teeth Count:Mostly Present Dentures:No Mouth Comments: Cranial Nerves: Intact 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 07/092019 13:03 by Bureau of Prisons - NYM Page 9 of 13 CONFIDENTIAL SDNY_00009436 EFTA00033842