Item 9, 13, 17 (partial), 18 (partial)

2019-05665 Item 9, 13, 17 (partial), 18 (partial) EFTA00073831 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 08/10/2019 07:25 Provider Reg #: 76318-054 M Race: WHITE Facility: NYM RN Unit: Z04 Emergency Code Resuscitation Event encounter performed at Special Housing Unit. SUBJECTIVE: Emergency Note Provider: RN Team Members: Provider Bole RN Team/Code Leader Code Events: Type Value Date CPR Compressions 08/10/2019 06:35 EKG/Monitor Lifepak 08/10/2019 06:39 No shock advised CPR Compressions 08/10/2019 06:40 Oxygen 15 L 08/10/2019 06:47 IV Access Peripheral IV 08/10/2019 06:48 18 g Left AC Page 001 of 148 Airway Endotracheal Tube 08/10/2019 07:08 Withheld pursuant to exemption ET Tube 7.5 24CM to L Lip line Placed by Paramedics Medications Epinephrine 1mg IV (b)(6) (b)(7)(A); (b)(7)(C) 08/10/2019 07:10 Epinephrine 3 doses and Sodium bicarb 2 doses administered by paramedics CPR Compressions of the Freedom of Information and Privacy Act, cro/10/2019 07:11 Medications Sodium Bicarbonate 1 mEaikg 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 mEaikg IV 08/10/2019 07:14 Medications Epinephrine 1mg IV 08/10/2019 07:16 CPR Compressions 08/10/2019 07:17 Comments: Responded to a body alarm at 0635 for medical emergency on 9S. Upon arrival Inmate was received on the floor of his cell unresponsive with CPR in progress by correctional officers, Inmate was Cold, with circumferential Bruising around the neck and posterior mottling, Pupils Fixed and dilated, No Palpable pulses, Call place for EMS, CPR Continued, AED Placed No shock advised, CPR Continued. inmate transported to HSU treatment room with CPR in progress, 18g hep lock to L AC, O2 15 Lt ViA BVM. Pulse Check NO SHOCK advised. EMS and Paramedics arrived 0656. Placed on cardiac monitor asystole Resumed CPR. Inmate was intubated by Medics. 3 Rounds of Epinephrine administered. Pulse Check asystole, Inmate was transported to Local ER with CPR in progress. OBJECTIVE: Exam: General Appearance Yes: Unconscious Generated 08 10 2019 08.10 by RN Bureau of Prisons - NYM Page 1 of 2 EFTA00073832 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 08/10/2019 07:25 Provider: RN Unit: Z04 Exam: ASSESSMENT: Cardiac Arrest PLAN: New Consultation Requests: Consultation/Procedure Target Date Scheduled Target Date Priority Translator Language Emergency Room 08/10/2019 08/10/2019 Emergent No Subtype: AMBULANCE Reason for Request: Cardiac arrest with CPR in progress Copay Required: No Cosign Required: Yes TelephoneNerbal Order: No Completed by RN on 08/10/2019 08:10 Requested to be cosigned by Cosign documentation will be displayed on the following page. Page 002 of 148 Withheld pursuant to exemption (b)(6) : (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Generated 08/1012019 08:10 by RN Bureau of Prisons NYM Page 2 of 2 EFTA00073833 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 08/10/2019 07:25 Provider: RN Facility: NYM Cosigned by on 08/12/2019 08:09. Page 003 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073834 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 15:58 Provider M Race: WHITE Reg #: 76318-054 Facility: NYM Unit: Z01 Chronic Care Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT WAS REFERRED BY THE WARDEN FOR EVALUATION. PATIENT REPORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO REPORTS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STATES THE NUMBNESS WENT AWAY ON ITS OWN. BUT WAS VERY CONCERNING. HE DENIES RIGHT SIDED WEAKNESS. DIPLOPIA. FACIAL DROOP. DIFFICULTY SPEAKING OR SWALLOWING. HE REPORTS NOCTURIA OF ABOUT 5 TIMES.. HE DENIES DYSURIA. HE REPORTS H OF KIDNEY STONES. HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEP APNEA AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HERE SINCE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE RECEIVED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-MEDICAL ISSUE rage uu4 of 148 STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Withheld pursuant to exemption Seen for clinic(s): Pulmonary/Respiratory. Orthopedic ,Rheumatology, Endocrine/Lipid (b)(6), (b)(7)(C) OBJECTIVE: of the Freedom of Information and Privacy Act 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: MITG Musculoskeletal Tibia / Fibula No: Edema Neurologic Generated 07 302019 16.12 by Bureau of Prisons - NYM Page 1 of 2 EFTA00073835 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Encounter Date: 07/30/2019 15:58 Sex: Provider M Race: WHITE Reg #: 76318-054 Facility: NYM Unit: 701 Exam: Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current Constipation, unspecified. K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, R7303 - Current Sleep apnea, G4730 - Current PLAN: Page 005 of 148 New Medication Orders: Rxtl Medication INsulin REG - Human Withheld pursuant to exemption Order Date (b)(8); (b)(dXM10;/0)(g)11%)58 of the Freedom of Information and Privacy Act Indication: Prediabetes Discontinued Medication Orders: Rx# Medication Order Date 122148-NYM Insulin Reg (10 ML) 100 UNITSML lnj 07/30/2019 15:58 Discontinue Type: When Pharmacy Processes Discontinue Reason: new order written Indication: Copay Required:No Telephone/Verbal Order: No Completed by Cosign Required: No on 07/30/2019 16:12 Prescriber Order SLIDING SCALE Subcutaneously each morning x 7 day(s) Pill Line Only Prescriber Order Inject regular insulin subcutaneously per sliding scale: twice daily —*pill line"' for 7 days Generated 0730:2019 16:12 by Bureau of Prisons - NYM Page 2 of 2 EFTA00073836 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 11:12 Provider: Reg #: 76318-054 Facility: NYM Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT PATIE ALS STAT HE DEN SPEAKING HE REPORT HE REPORTS TOPROL. HE AHS A HX OF SLEEP ISNCE HE HASB EEN INFORME DHIM THAT WE HIM TONIGHT.. HE REPORT OTHER NON-ME STATES HE FEELS OTHERWISE PIN Pain: Not Applicable Withheld REFERRED BY THE WARDEN FOR EVALUATION. RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY OWING. IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING AND STATED HE HAS NOT SLEPT FOR 3 WEEKS E HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I HIS CPAP MACHINE AND IT WILL BE GIVEN TO Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology' (b)(6) (b)( OBJECTIVE: Pulse: Dale 07/30/2019 07/30/2019 07/30/2019 Respirations: pate Time 07/30/2019 09:30 NYM €W8 of 148 o exemption of the Freedom of Information lime Rate Per Minute 13:02 94 09:40 88 09:30 87 Location Via Machine Via Machine Rate Per Minute Provider Blood Pressure: Date limes Value Location 07/30/2019 13:02 NYM 114/84 Left Arm 07/30/2019 09:40 NYM 125/60 Right Arm 07/30/2019 09:30 NYM 108/86 Left Arm SaO2: Dale lime Value(%) Air 07/30/2019 09:30 NYM 98 Room Air Weight: Date Time Lbs 12 Respiratory XC) Position Standing Standing Sitting Provider eaudouin, Robert MD &Quin. Robert MD Robert MD Cuff Size Provider Provider Kg Waist Circum. Provider Generated 07/30/2019 14:05 by Bureau of Prisons - NYM Page 1 of 3 EFTA00073837 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 11:12 Provider: Reg #: 76318-054 M Race: WHITE Facility: NYM Unit: Z01 Date Time Lba Kg Waist Circum, Provider 07/30/2019 09:30 NYM 194.2 88.1 Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distr ed. Dyspneic. Appears in Pain. Writhing in Pain, Pale. Pallor. Cyanotic, Diaphoretic. Disheveled, Unk cutely III Nutrition No: Appears O Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR 1 and S2 No: Mil(G Musculoskeletal Tibia / Fibula No: Edema Neurologic Cranial Nerves (CN) of the Freedom of Information Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Withheld e 007 of 148 exemption (b)(8). (b)(7) ( )(C) 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 Prediabeles, R7303 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: R x# Medication Order Date Prescriber Order Generated 07/30.2019 14.05 by Bureau of Prisons - NYM Page 2 of 3 EFTA00073838 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 11:12 Provider Reg #: 76318-054 M Race: WHITE Facility: NYM Unit: Z01 New Medication Orders: Rx# Medication Magnesium Hydroxide Susp conc 800 MG15ML Indication: Constipation. unspecified INsulin REG - Human Indication: Prediabetes Renew Medication Orders: Rxff Medication Order Date Prescriber Order 121836-NYM methylP ne 4 MG Tab ( 21 count 07/30/2019 11:12 Take the tablet by mouth as Pack) directed x 6 day(s) Indication: a and neuritis, unspecified New Laboratory Requests: Details Frequency Due Date Priority Lab Tests - Short List-General-CBC w diff ane Time 08/01/2019 00:00 Routine Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short List-General-Comprehensiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic New Radiology Request Orders: Order Date 07/30/2019 11:12 07/30/2019 11:12 Prescriber Order 10 CC Orally - Two Times a Day PRN x 90 day(s) SLIDING SCALE Subcutaneously - Two Times a Day x 7 day(s) Pill Line Only 008 of 148 Withheld e emption Details Frequency Due Date General Radiology -Spine / Cervical- One Ti(ix)(6); (b)( )(C) 08/29/2019 General Specific reason(s) for request (ttfififtSiffigraei6 InfRnalje 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI PLEASE PERFORM C SPINE SERIES Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date initiated Format 07/30/2019 Counseling Handout/Topic Access to Care 07/30/2019 Counseling Plan of Care Copay Required:No Cosign Required: No Telephone, Verbal Order: No Completed by on 07/30/2019 14:05 Priority Routine 2-3 MINUTES 3 DAYS AGO. Pipit l Outcome Beaudo Robert Verbalizes Understanding Verbalizes Understanding Generated 07 30'2019 14:05 by Bureau of Prisons - NYM Page 3 of 3 EFTA00073839 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT REFERRED BY THE WARDEN FOR EVALUATION. PATIE RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALS E 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 DEN HI SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OWING. HE REPORT IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. HE REPORTS 'NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEP AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN CE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE EBED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-ME STATES HE FEELS OTHERWISE PIN Pain: Not Applicable Withhelddi o exemption Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology, Respiratory (b)(6) (b)( )(C) OBJECTIVE: Pulse: Date Time Rate Per Minute Location 07/30/2019 13:02 94 07/30/2019 09:40 88 Via Machine 07/30/2019 09:30 87 Via Machine of the Freedom of Information Respirations: Date lime Rate Per Minute Provider 07/30/2019 09:30 NYM 12 Blood Pressure: Data 07/30/2019 07/30/2019 07/30/2019 SaO2: Time Value Location Position 13:02 NYM 114/84 Left Arm Standing 09:40 NYM 125/60 Right Arm Standing 09:30 NYM 108/86 Left Arm Sitting Provider eaudouin, Robed MD eouin. Robed MD Robert MD Cuff Size Provider Date Time Value(%) Alt Provider 07/30/2019 09:30 NYM 98 Room Air Weight: Pale Time Lin Kg Waist Circum. Provider Generated 07/3012019 14:05 by Bureau of Prisons - NYM Page 1 of 3 EFTA00073840 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 11:12 Provider: M Race: WHITE Reg #: 76318-054 Facility: NYM Unit: Z01 Dale Time 07/30/2019 09:30 NYM 194.2 88.1 LIM Kg Waist Circum Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distr ed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unk cutely III Nutrition No: Appears O Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR No: M•IG Musculoskeletal Tibia / Fibula No: Edema Neurologic Cranial Nerves (CN) of the Freedom of Information Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: 1 and S2 e 010 of 148 le exemption (b)(6): (b)( ) • (• )(C) 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: Exit Medication Order Date Prescriber Order Generated 07/3012019 14:05 by Bureau of Prisons - NYM Page 2 of 3 EFTA00073841 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: Unit: Z01 New Medication Orders: BLit( Medication Order Date Prescriber Order Magnesium Hydroxide Susp conc 800 07/30/2019 11:12 10 CC Orally - Two Times a MG/5ML Day PRN x 90 day(s) Indication: Constipation, unspecified INsulin REG - Human 07/30/2019 11:12 SLIDING SCALE Subcutaneously Two Times a Day x 7 day(s) Pill Line Only Indication: Prediabetes Renew Medication Orders: &ft Medication Order Date Prescriber Order 121836-NYM methylP ne 4 MG Tab ( 21 count 07/30/2019 11:12 Take the tablet by mouth as Pack) directed x 6 day(s) Indication: a and neuritis, unspecified New Laboratory Requests: Details Frequency Lab Tests - Short List-General-CBC w diff ane Time Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short List-General-Comprehensiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic New Radiology Request Orders: Details General Radiology -Spine / Cervical- General Specific reason(s) for request ft 8ffirfffeftliekilfliRMISP 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI PLEASE PERFORM C SPINE SERIES Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format Handout/Topic Prov Outcome 07/30/2019 Counseling Access to Care Beaudo Robert Verbalizes Understanding 07/30/2019 Counseling Plan of Care Verbalizes Understanding Frequency One Ti0b)(6); (b e 011 of 148 Due Date 08/01/2019 00:00 Routine Priority e emption Due Date )(C) 08/29/2019 Priority Routine 2-3 MINUTES 3 DAYS AGO. Copay Required:No Cosign Required: No TelephoneNerbal Order: No Completed by on 07/30/2019 14:05 Generated 07130/2019 14:05 by Bureau of Prisons - NYM Page 3 of 3 EFTA00073842 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 15:58 Facility: NYM Amendment made to this note by on 07/30/2019 16:12. Page 012 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons - NYM EFTA00073843 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/28/2019 20:25 Provider Reg #: 76318-054 M Race: WHITE Facility: NYM RN Unit: H01 Nursing - Follow up encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: RN Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies) Subjective: Inmate seen for F/U after returning from attorney conference offers no new complaints or worsening S/S stats My, hand still has pins and needles sometimes" No change in appearance from previous exam. Pain: No OBJECTIVE: Pulse: Date Time 07/28/2019 20:28 Respirations: Date 07/28/2019 Blood Pressure: Date Time 07/28/2019 20:28 NYM SaO2: Date Time yatue(%) Air 07/28/2019 20:28 NYM 98 Rate Per Minute Location Rhythm Provider Time 20:28 NYM Value 157/91 Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 Nutrition Yes: Within Normal Limits Skin General Yes: Within Normal Limits. Dry. Skin Intact ASSESSMENT: No Significant Findings/No Apparent Distress PLAN: Disposition: To be Evaluated by Provider Generated 0712812019 20:30 by 81 Rate Per Minute Provider 14 Withheld pursuant to exemption Location (b)WPO:jR9)(A): (b)Filk-PiZe of the Freedom of Information and Privacy Act ProviderProvider RN RN RN RN Bureau of Prisons - NYM Page 1 of 2 EFTA00073844 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/28/2019 20:25 Provider Reg #: 76318-054 M Race: WHITE Facility: NYM RN Unit: H01 Follow-up in 12-24 Hours Patient Education Topics: ttate_lnitiated Formal Handout/Topic 07/28/2019 Counseling Plan of Care Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Completed by RN on 07/28/2019 20:30 Requested to be cosigned by Cosign documentation will be displayed on the following page. Page 014 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Provider Outcome Verbalizes Understanding Generated 07/28/2019 20:30 by RN Bureau of Prisons - NYM Page 2 of 2 EFTA00073845 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/28/2019 20:25 Provider: RN Facility: NYM Cosigned by on 07/28/2019 20:50. Page 015 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073846 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: RN Unit: H01 Nursing - Triage Note encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: RN Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies) Subjective: " I woke up and I had no control over my Right arm for a few minutes it was just doing what it wanted to do" Pain: No OBJECTIVE: Pulse: Dale Time 07/28/2019 06:57 Rate Per Minute location Rhythm Provider 82 Respirations: DAM lime Rate Per Minute Pr vider 07/28/2019 06:57 NYM 14 Blood Pressure: Dale Time Value LocationWithhe0cPtlif8iint to extaidni(gi ze 07/28/2019 06:57 NYM 138/80 (b)(6) : (b)(7)(A): (b)(7)(C) SaO2: of the Freedom of Information and Privacy Act DAM Time ValuerY41 Alt Provider 07/28/2019 06:57 NYM 98 Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 Skin General Yes: Within Normal Limits, Dry, Skin Intact Head General Yes: Symmetry of Motor Function, AtraumaticlNormocephalic No: Facial Asymmetry, Battle's Sign, Raccoon Eyes, Deformity Eyes General Yes: , Extraocular Movements Intact Face General Yes: Symmetric Generated 07128;2019 07:22 by■ RN Provider RN RN RN Bureau of Prisons - NYM Page 1 of 3 EFTA00073847 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/28/2019 06:51 Provider Reg #: 76318-054 M Race: WHITE Facility: NYM RN Unit: H01 Exam: No: Ecchymosis, Numbness, Swelling. Periorbital Edema Neck General Yes: Abrasion(s) Pulmonary Observation/Inspection Yes: Within Normal Limits No: Respiratory Distress, Tachypnea, Hyperventilation Cardiovascular Observation Yes: Normal Rate Musculoskeletal Shoulder Yes: Full Range of Motion Symmetric, No: Swelling I, Inflammation' Humerus Yes: Within Normal Limits, Elbow Yes: Normal Exam I, Full Range of Motion', Nikkfie0tnicibrlifeilpation I Radius / Ulna Withhdd pursuant to exemption Yes: Normal Exam Full Range of Motion I Wrist/Hand/Fingers (b)(6); (b)(7)(A) ; (b)(7)(C) Yes: Full Range of Motion RoNtitio*HefRAAtigoog•Awitleiviic9 Act No: Inflammation I. Ecchymosis Erythema'. Tenderness Laceration(s) I, Abrasion(s) I, Contusion(s) I ROS Comments Received inmate AAOX3 in no acute distress, speaking in full sentenced ambulating independently C/O Right arm numbness after waking up from "sleeping on my side" that has since subsided. inmate interviewed in psyc obs through the slot. ViS noted WNL. RR even and unlabored, no neurological deficits noted, no facial droop slurred speech or dysphagia. Inmate with Full ROM to all extremities with 4/4 strength bilaterally • slight swelling noted to right phalanges when compared to left, no edema, erythema or ecchymosis noted. Denies an ain numbness or tingling at this time. Denies any Chest pain, Headache, Dizziness, SOB or Blurred vision. Eyes . MD on Call notified. Re-evaluate this evening or sooner if S/S persist. ASSESSMENT: Alteration in comfort PLAN: Disposition: Follow-up at Sick Call as Needed Notify Medical Duty Officer Patient Education Topics: Pate Initiated Format Handout/Topic Provider Outcome 07/28/2019 Counseling Plan of Care Verbalizes Understanding Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM Page 2 of 3 EFTA00073848 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/28/2019 06:51 Provider: Reg #: 76318-054 M Race: WHITE Facility: NYM RN Unit: H01 Date Initiated Format Randoutagpic Provider Outcome Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Completed by RN on 07/28/2019 07:22 Requested to be cosigned by Cosign documentation will be displayed on the following page. Page 018 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM Page 3 of 3 EFTA00073849 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/28/2019 06:51 Provider: RN Facility: NYM Cosigned by on 07/28/2019 20:51. Page 019 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073850 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Note Date: 07/26/2019 08:57 Provider: Reg #: 76318-054 Parr WHITE Facility: NYM Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. New Medication Orders: That Medication Order Date Prescriber Order Docusate Sodium Capsule 07/26/2019 08:57 TAKE ONE 100 MG CAP Orally - Two Times a Day x 180 day(s) Indication: Constipation, unspecified Copay Required:No Telephone Verbal Order: No Completed by Cosign Required: No on 07/26/2019 08:58 Page 020 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A) (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07126,2019 08:58 by Bureau of Prisons NYM Page I of I EFTA00073851 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: Rate WHITE Facility: NYM Note Date: 07/24/2019 16:10 Provider: Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. Copay Required:No Telephone/Verbal Order: Completed by Cosign Required: No 24/2019 16:12 1 e 021 of 148 i.co Withheld exemption (b)(6) ; (b) ) , ( )(C) of the Freedom of Information Generated 07/24/2019 16:12 by Bureau of Prisons - NYM Page 1 of 1 EFTA00073852 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: Rare-WHITE Facility: NYM Note Date: 07/24/2019 16:10 Provider: Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. Copay Required:No Telephone/Verbal Order: Completed by Cosign Required: No 24/2019 16:12 1 ile 022 of 148 p Withheld o exemption (b)(6) ; (b) , ( )(C) of the Freedom of Information Generated 07/24/2019 16:12 by Bureau of Prisons - NYM Page 1 of 1 EFTA00073853 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/26/2019 08:57 Facility: NYM Amendment made to this note by on 07/26/2019 08:58. Page 023 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons - NYM EFTA00073854 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: m Rare•WHITE Facility: NYM Note Date: 07/24/2019 15:10 Provider: Unit: H01 Admin Note - General Administrative Note encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: PATIENT WAS OFFERED TO HAVE AN OPTOMETRIST EVALUATION. HE REFUSED. REFUSAL FORM SIGNED. Copay Required:No TelephoneNerbal Order: No Completed by Cosign Required: No on 07/24/2019 15:17 Page 024 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/24/2919 15:17 by Bureau of Prisons - NYM Page 1 of 1 EFTA00073855 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/24/2019 13:08 Provider: Unit: H01 Mid Level Provider Follow up Visit encounter performed at Receiving & Discharge. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: I still do not want to talk about. But, between you and me. I think my room mate had to do with what happened to me. Do not ask me. I am not going to say anything. Pain: No OBJECTIVE: Temperature: Date Tittle Fa_hienteit GetSiu_s LOCatiOn Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/24/2019 13:12 83 Via Machine Regular Page 025 of 148 Blood Pressure: Date Time Value LocationWithheislamnt to extriiiiivze Provider 07/24/2019 13:12 NYM 132/89 Right Arm (b) jtirm(7)(A) : (b)Mayegular SaO2: of the Freedom of Information and Privacy Act Date Time Value(%) Air Provider 07/24/2019 13:12 NYM 96 Room Air Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed. Appears in Pain Exam Comments Follow up evaluation done for inmate Epstein. He does not look in any pain or distress. He still has the erythema around his neck. Central part of this erythema has some abrasion. Patient does not complaint of any respiratory problem or distress. He still does not want to explain how the skin injury on his neck happed. he insinuates that injuries on his neck have to do with his room male. But does not want to talk about it. ASSESSMENT: Injury, unspecified. T1490 - Current PLAN: Disposition: Generated 07 24 2019 13.24 by Bureau of Prisons - NYM Page 1 of 2 EFTA00073856 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/24/2019 13:08 Provider: Reg #: 76318-054 Facility: NYM Unit: H01 Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format 07/24/2019 Counseling 07/24/2019 Counseling Copay Required:No Telephone/Verbal Order: No Completed by on 07/2412019 13:24 Requested to be cosigned by Cosign documentation will be displayed on the following page. Handout/Topic Access to Care Preventive Health Cosign Required: Yes Page 026 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Provider Outcome Verbalizes Understanding Verbalizes Understanding Generated 07)242019 1324 by Bureau of Prisons • NYM Page 2 of 2 EFTA00073857 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/24/2019 13:08 Provider: Facility: NYM Cosigned with New Encounter Note by on 07/24/2019 16:10. Page 027 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073858 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: Unit: H01 Injury Assessment Non-work related encounter performed at Health Services. SUBJECTIVE: INJURY 1 Provider: Date of Injury: 07/23/2019 01:27 Date Reported for Treatment: 07/23/2019 08:25 Work Related: No Work Assignment: UNASSG Pain Location: Pain Scale: 0 Pain Qualities: Where Did Injury Happen (Be specific as to location): Special Housing Unit Z05-Cell 124 L Cause of Injury (Inmate's Statement of how injury occurred): "I do not know. Just went to drink a little water and wake up snorting". Symptoms (as reported by inmate): None Page 028 of 148 OBJECTIVE: Withheld pursuant to exemption Temperature: u(b)aartigr)i(A) ; (b)(71(C) . Date Time Fahrenheit Cglsi_s Provider 07 23 2019 06:30 NYM 91.Se FreeSOPA o(ynibrmation and PthsvOlip1Y. MLP Pulse: Dale Time Rate Per Minute Location 07723/2019 06:30 92 Via Machine Regular Respirations: Date Time Rate Per Minute Provider 07/23/2019 06:30 NYM 16 Blood Pressure: Date Time Value Location Position 07/23/2019 06:30 NYM 140/85 Right Arm Sitting Adult-regular SaO2: Date Time Value(%) Air Provider 07/23/2019 06:30 NYM 96 Room Air Rhy►hm Provider Cuff Size Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Lethargic. Dyspneic, Appears in Pain, Pallor, Cyanotic, Diaphoretic, Disheveled, Generated 0712312019 09.05 by Bureau of Prisons NYM Page 1 of 2 EFTA00073859 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: Unit: H01 Exam: Acutely III Pulmonary Auscultation Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally No: Crackles, Rhonchi, Wheezing Exam Comments Inmate for injury report as requested by Operational Lt. He is ambulatory, oriented x 3. In not apparent distress, smiling during this clinical encounter. Alleges. that he does not know what happened. Can not explain the marks on his neck. Responded: "I don't know". He does not want to talk of the events leading to the marks on his neck. He does not look in any distress or pain. Has an circular line of erythema at the base of the neck. Reaching 2/3 of the neck circumference, 2 inches wide, sparing the back of the neck. Has one section of this erythema in the front with marks of friction. No inflammation, no deformities, no hematomas. no lacerations, no tenderness. Patient moving his neck without any restriction. Denies having any pain or discomfort. Denies any respiratory problem. Has another small erythema on left knee about 2cm in diameter(mild). As per information from custody staff inmate Epstein was found in his cell with a rope around his neck and sitting on the floor. Inmate is currently placed on suicide watch. ASSESSMENT: Page 029 of 148 Injury, unspecified, T1490 - Current -'iO self inflicted injuries. Withheld pursuant to exemption PLAN: (b)(6). (b)(7)(A) (b)(7)(C) Disposition: Follow-up at Sick Call as Needed Placed on Suicide Watch Follow-up in 2-4 Hours of the Freedom of Information and Privacy Act Other: For follow up with psychology service. Patient Education Topics: Date Initiated Format Handout/Topic Provider Outcome 07/23/2019 Counseling Access to Care Verbalizes Understanding 07/23/2019 Counseling Plan of Care Verbalizes Understanding Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Completed by on 07`23 2019 09:05 Requested to be cosigned by Cosign documentation will be displayed on the following page. Generated 07/23/2019 09:05 by Bureau of Prisons - NYM Page 2 of 2 EFTA00073860 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/23/2019 06:20 Provider: Facility: NYM Cosigned by on 07/23/2019 15:44. Page 030 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073861 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/14/2019 17:36 Provider Reg #: 76318-054 M Race: WHITE Facility: NYM Unit: Z05 Chronic Care 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDOLIPID Subjective: 66 YR OLD WHITE MALE WITH HX OF HYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , NOW 431. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS DUE TO THEIR GI SIDE EFFECTS. HX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE FBI LOKELY HAS L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES. SURGICAL HX: NONE MENTAL HEALTH HX: NONE Pain: Yes Pain Assessment Date: 07/12/2019 13:25 Page 031 of 148 Location: Back-Middle Withheld pursuant to exemption Quality of Pain: Shooting Pain Scale: 5 (b)(6); (b)(7)(A); (b)(7)(C) Intervention: MEDRerl-take86‘616f Information and Privacy Act Trauma Date'Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: Seen for clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid Added to clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid OBJECTIVE: Exam: General Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed. Dyspneic. Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt. Acutely III Nutrition No: Appears Obese Generated 07/1422019 18:11 by Bureau of Prisons - NYM Page 1 of 3 EFTA00073862 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/14/2019 17:36 Provider: Reg #: 76318-054 Facility: NYM Unit: Z05 Exam: Eyes General Yes: , Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2 No: Milt Abdomen Auscultation Yes: Normo-Active Bowel Sounds Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back Yes: Tenderness Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam ASSESSMENT: Page 032 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A) , (b)(7)(C) of the Freedom of Information and Privacy Act 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: RAE Medication Omega 3 ( Vascepa) 1 GM Capsule Order Date 07/14/2019 17:36 Indication: Hyperlipidemia, unspecified New Laboratory Requests: Details Frequency Lab Tests-H-Hemoglobin A1C One Time Lab Tests-L-Lipid Profile Additional Information: Generated 07/14/2019 18:11 by Prescriber Order TAKE 2 CAPS Orally - Two Times a Day x 180 day(s) -- TAKE WITH FOOD. Due Date Priority 10/10/2019 00:00 Routine Bureau of Prisons - NYM Page 2 of 3 EFTA00073863 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/14/2019 17:36 Provider Reg #: 76318-054 M Race: WHITE Facility: NYM Unit: Z05 FASTING. 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: One Time 08/08/2019 00:00 Routine 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: Qate_initiated Format Handout/Topic 07/14/2019 Counseling Diagnosis Copay Required: No Cosign Required: N9age 033 of 148 Telephone Verbal Order: No Withheld pursuant to exemption Completed by 011 07 14.'2019 18:11 (b)(6); (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Provider Outcome Verbalizes Understanding Generated 07/14/2019 18:11 by Bureau of Prisons - NYM Page 3 of 3 EFTA00073864 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/12/2019 13:10 Provider M Race: WHITE Reg #: 76318-054 Facility: NYM Unit: Z05 Chronic Care 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDOiLIPID Subjective: 66 YR O HITE MALE WITH HX OF HYPER CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 . STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MED EIR GI SIDE EFFECTS. HX OF UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES TH Y HAS L4 - L5 SEVERE SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREM S. SURGICAL HX: NONE MENTAL HEALTH HX: Pain: Yes Pain Assessment Date: Location: Quality of Pain: Pain Scale: Intervention: MEDRatlig:ISielaitWlef Information Trauma Date'Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: 07/1212019 13:25 C Se 034 of 148 Back-Middle Withheld bt4o exemption Shooting 5 (b)(6): (b)(7) , (' - )(C) 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 07ft2/2019 14:20 by Bureau of Prisons - NYM Page 1 of 3 EFTA00073865 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/12/2019 13:10 Provider: Reg #: 76318-054 Facility: NYM Unit: Z05 Exam: Eyes General Yes: , Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal S1 and S2 No: Mit Abdomen Auscultation Yes: Normo-Active Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back Yes: Tenderness Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam ASSESSMENT: e 035 of 148 le o exemption (b)(6) : (b)( ) )(C) of the Freedom of Information 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 Magnesium Hydroxide Susp 07/12/2019 13:10 Indication: Constipation, unspecified MethylPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 Pack 21 tab) Indication: Neuralgia and neuritis, unspecified Disposition: Prescriber Order 30 CC Orally - Two Times a Day PRN x 2 day(s) AS DIRECTED Orally - daily x 6 day(s) Generated 07/12/2019 14:20 by Bureau of Prisons - NYM Page 2 of 3 EFTA00073866 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/12/2019 13:10 Provider M Race: WHITE 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: Date Initiated Format Handout/Topic 07/12/2019 Counseling Diagnosis Copay Required:No Telephone/Verbal Order: Completed by Beaudouin, Cosign Required: No 07/12/2019 14:20 4 e 036 of 148 ullo Withheld exemption (b)(6) ; (b) ) , ( )(C) of the Freedom of Information Provider Outcome Verbalizes Understanding Generated 07:12 2019 1420 by Bureau of Prisons - NYM Page 3 of 3 EFTA00073867 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/12/2019 13:10 Provider M Race: WHITE Reg #: 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 0 HYPER 800 . MED HX OF MACHINE. STATES TH L4 - L5 SEVERE LOWER EXTREM S. SURGICAL HX: NONE MENTAL HEALTH HX: Pain: Yes Pain Assessment Date: Location: Quality of Pain: Pain Scale: Intervention: Trauma Date Year: Injury: Mechanism: Onset: Duration: Exacerbating Factors: Relieving Factors: Reason Not Done: Comments: HITE MALE WITH HX OF CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE EIR GI SIDE EFFECTS. UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. Y HAS SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE 07/12/2019 13:25 Back-Middle Shooting 5 Withheld e 037 of 148 o exemption (b)(6): (b)( )(C) MEDRQ.tfAClb€e86Fil6f Information 5+ Years 5+ Years NO EXERCISE MEDROL DOSE PACK Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology OBJECTIVE: Exam: General Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed. Dyspneic. Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled. Unkempt. Acutely III Nutrition No: Appears Obese Generated 07/12/2019 14:20 by Bureau of Prisons - NYM Page 1 of 3 EFTA00073868 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/12/2019 13:10 Provider: Reg #: 76318-054 Facility: NYM Unit: Z05 Exam: Eyes General Yes: , Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal S1 and S2 No: Milt Abdomen Auscultation Yes: Normo-Active Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back Yes: Tenderness Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam ASSESSMENT: e 038 of 148 exemption (b)(6) ; (b)(7) ( )(C) of the Freedom of Information 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: 8/iff Medication Order Date Magnesium Hydroxide Susp 07/12/2019 13:10 Indication: Constipation, unspecified MethylPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 Pack 21 tab) Indication: Neuralgia and neuritis, unspecified Disposition: Prescriber Order 30 CC Orally - Two Times a Day PRN x 2 day(s) AS DIRECTED Orally - daily x 6 day(s) Generated 07/12/2019 14:20 by Bureau of Prisons - NYM Page 2 of 3 EFTA00073869 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: Unit: Z05 Follow-up at Sick Call as Needed Other: WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP. Patient Education Topics: Date Initiated Format 07/12/2019 Counseling Copay Required:No Telephone/Verbal Order: Completed by Beaudouin, Handout/Topic Provider Outcome Diagnosis Verbalizes Understanding Cosign Required: No 07/12/2019 14:20 4 039 of 148 Withheld Le o exemption e (b)(6) , (b)( ) )(C) of the Freedom of Information Generated 07:12,2019 14:20 by Bureau of Prisons - NYM Page 3 of 3 EFTA00073870 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 07/14/2019 18:11. Page 040 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons - NYM EFTA00073871 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: Date of Birth: Note Date: EPSTEIN, JEFFREY EDWARD 01/20/1953 Sex: Rana. WH ITF 07/12/2019 09:06 Provider: Reg #: Facility: Unit: 76318.054 NYM Z05 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: fixE Medication Order Date Docusate Sodium Capsule 07/12/2019 09:06 Indication: Constipation, unspecified Discontinued Medication Orders: Bx# Medication Order Date 121757-NYM Bisaoodyl E.C. 5 MG TAB 07/12./2019 09:06 Discontinue Type: When PharmacThicaises Di 148 Discontinue Reason:discoggilhheld pursuant to exemption Indication: Copay Required:No TelephoneNerbal Order: No Completed by (b)(6) : (b)(7)(A), (b)(7)(C) Cosign Required: No of the Freedom of Information and Privacy Act on 07/12/2019 09:10 Prescriber Order TAKE ONE 100 MG CAP Orally - Two Times a Day x 30 day(s) Prescriber Order Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10 days Generated 07/122019 09:10 by Bureau of Prisons NYM Page 1 of 1 EFTA00073872 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: Date of Birth: Note Date: EPSTEIN, JEFFREY EDWARD 01;201953 Sex: 07/07/2019 00:17 Provider: Reg IS: 76318-054 Rant, WHITE Facility: NYM Unit: E06 Cosign Note