Bureau of Prisons

Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 08/10/2019 07:25 Provider: RN Unit: Z04 Emergency Code - Resuscitation Event encounter performed at Special Housing Unit. SUBJECTIVE: Emergency Note Provider: Team Members: Provider RN Bole Team/Code Leader RN Code Events: IYRe Value Date CPR Compressions 08/10/2019 06:35 EKG/Monitor Lifepak 08/10/2019 06:39 No shock advised CPR Compressions 08/10/2019 06:40 Oxygen 15 L 08/10/2019 06:47 IV Access Peripheral IV 08/10/2019 06:48 18 g Left AC Airway Endotracheal Tube ET Tube 7.5 24CM to L Lip line Placed by Paramedics 08/10/2019 07:08 Medications Epinephrine 1mg IV 08/10/2019 07:10 Epinephrine 3 doses and Sodium bicarb 2 doses administered by paramedics CPR Compressions 08/10/2019 07:11 Medications Sodium Bicarbonate 1 mEa/kg IV 08/10/2019 07:11 IV Fluids Normal Saline 0.9% 1000 ml 08/10/2019 07:12 Medications Epinephrine 1mg IV 08/10/2019 07:13 CPR Compressions 08/10/2019 07:14 Medications Sodium Bicarbonate 1 mEa/kg IV 08/10/2019 07:14 Medications Epinephrine 1mg IV 08/10/2019 07:16 CPR Compressions 08/10/2019 07:17 Comments: Responded to a body alarm at 0635 for medical emergency on 9S, Upon arrival Inmate was received on the floor of his cell unresponsive with CPR in progress by correctional officers, Inmate was Cold, with circumferential Bruising around the neck and posterior mottling, Pupils Fixed and dilated, No Palpable pulses, Call place for EMS, CPR Continued, AED Placed No shock advised, CPR Continued, inmate transported to HSU treatment room with CPR in progress, 18g hep lock to L AC, O2 15 Lt ViA BVM, Pulse Check NO SHOCK advised. EMS and Paramedics arrived 0656, Placed on cardiac monitor asystole Resumed CPR, Inmate was intubated by Medics, 3 Rounds of Epinephrine administered, Pulse Check asystole, Inmate was transported to Local ER with CPR in progress. OBJECTIVE: Exam: General Appearance Yes: Unconscious Generated 08/1012019 08:10 by RN Bureau of Prisons - NYM SDNY_0001 :745641 of 2 EFTA00138991 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 08/10/2019 07:25 Provider: RN Unit: Z04 Exam: ASSESSMENT: Cardiac Arrest PLAN: New Consultation Requests: Consultation/Procedure Target Date Scheduled Target Date Priority Translator Language Emergency Room 08/10/2019 08/10/2019 Emergent No Subtype: AMBULANCE Reason for Request: Cardiac arrest with CPR in progress Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Completed by RN on 08/10/2019 08:10 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 08,10,2019 08:10 by RN Bureau of Prisons - NYM SDNY_0001-71.55 rage 201 2 EFTA00138992 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 08/10/2019 07:25 Provider: RN Facility: NYM Cosigned by MD on 08/12x2019 08:09. Bureau of Pesons NYM SDNV_00017356 EFTA00138993 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 15:58 Provider: MD Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: MD Chief Complaint: Other Problem Subjective: PATIENT WAS REFERRED BY THE WARDEN FOR EVALUATION. PATIENT REPORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO REPORTS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STATES THE NUMBNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. HE DENIES RIGHT SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OR SWALLOWING. HE REPORTS NOCTURIA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. HE REPORTS H OF KIDNEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEP APNEA AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HERE SINCE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE RECEIVED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-MEDICAL ISSUES. STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Seen for clinic(s): Pulmonary/Respiratory, Orthopedic/Rheumatology, Endocrine/Lipid OBJECTIVE: Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely III Nutrition No: Appears Obese Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2 No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neurologic Generated 07/30/2019 16:12 by MD Bureau of Prisons - NYM SONY_0001-7257 raga 1 of 2 EFTA00138994 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 15:58 Provider: MD Reg #: 76318-054 Facility: NYM Unit: Z01 Exam: Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current Constipation, unspecified, K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, R7303 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: Eta Medication INsulin REG - Human Indication: Prediabetes Discontinued Medication Orders: Eta Medication 122148-NYM Insulin Reg (10 ML) 100 UNITS/ML lnj Order Date 07/30/2019 15:58 Order Date 07/30/2019 15:58 Discontinue Type: When Pharmacy Processes Discontinue Reason:new order written Indication: Copay Required:No Telephone/Verbal Order: No Completed by Cosign Required: No MD on 07/30/2019 16:12 Prescriber Order SLIDING SCALE Subcutaneously each morning x 7 day(s) Pill Line Only Prescriber Order Inject regular insulin subcutaneously per sliding scale: twice daily —*pill linen* for 7 days SDNY Generated 071302019 16:12 by _000 MD Bureau of Prisons - NYM 1102 of 2 EFTA00138995 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 11:12 Provider: MD Reg #: 76318-054 Facility: NYM Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT PATIE ALS STAT HE DEN SPEAKING HE REPORT HE REPORTS TOPROL. HE AHS A HX OF SLEEP ISNCE HE HASB EEN INFORME DHIM THAT WE HIM TONIGHT.. HE REPORT OTHER NON-ME STATES HE FEELS OTHERWISE Pain: Not Applicable MD REFERRED BY THE WARDEN FOR EVALUATION. RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY OWING. IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING AND STATED HE HAS NOT SLEPT FOR 3 WEEKS E HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I HIS CPAP MACHINE AND IT WILL BE GIVEN TO ES. OBJECTIVE: Pulse: Date Time Rate Per Minute Location 07/30/2019 13:02 94 07/30/2019 09:40 88 Via Machine 07/30/2019 09:30 87 Via Machine Respirations: Date Time 07/30/2019 09:30 NYM Rate Per Minute Provider 12 Blood Pressure: Date Time Value Location Position 07/30/2019 13:02 NYM 114/84 Left Arm Standing 07/30/2019 09:40 NYM 125/60 Right Arm Standing 07/30/2019 09:30 NYM 108/86 Left Arm Sitting SaO2: Date Time Value(%) Air 07/30/2019 09:30 NYM 98 Room Air Weight: Date Time )1 Cuff Size Provider Provider Lim Kg Waist Circum Provider MD D MD MD MD Generated 07/30/2019 14:05 by MD Bureau of Prisons - NYM SDNY_0001/0 1 of 3 Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology,4 Respiratory EFTA00138996 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 11:12 Provider: M Race: WHITE Reg #: 76318-054 Facility: NYM MD Unit: Z01 Date lime 07/30/2019 09:30 NYM 194.2 88.1 MD Lbs Kg Waist Circum. Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distr ed. Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unk cutely III Nutrition No: Appears O Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0.27.9, adult. Z6827 - Current Constipation, unspecified, K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, 87303 - Current Sleep apnea, G4730 - Current 1 and S2 PLAN: New Medication Orders: BXg Medication Order Date Prescriber Order 2 of 3 Generated 07)30,2019 14:05 by MD Bureau of Prisons - NYM SDNY_OOOWN EFTA00138997 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 11:12 Provider: MD Reg #: 76318-054 Facility: NYM Unit: Z01 New Medication Orders: fiat Medication Order Date Magnesium Hydroxide Susp conc 800 07/30/2019 11:12 MG/5ML Indication: Constipation, unspecified INsulin REG - Human 07/30/2019 11:12 Indication: Renew Medication Orders: Medication 121836-NYM methylP Pack) Indication: New Laboratory Requests: Details Frequency Lab Tests - Short List-General-CBC w diff one Time Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short List-General•Comprehensiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic New Radiology Request Orders: Details General Radiology -Spine / Cervical- General Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NU PLEASE PERFORM C SPINE SERIES Prediabetes Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format 07/30/2019 Counseling 07/30/2019 Counseling Copay Required:No Telephone/Verbal Order: No Completed by ne 4 MG Tab ( 21 count Order Date 07/30/2019 11:12 a and neuritis, unspecified Frequency One Time Handout/Topic Access to Care Plan of Care Cosign Required: No MD on 07/30/2019 14:05 Prescriber Order 10 CC Orally • Two Times a Day PRN x 90 day(s) SLIDING SCALE Subcutaneously • Two Times a Day x 7 day(s) Pill Line Only Prescriber Order Take the tablet by mouth as directed x 6 day(s) Due Date 08/01/2019 00:00 Due Date 08/29/2019 Priority Routine Priority Routine R 2-3 MINUTES 3 DAYS AGO. Outcome Verbalizes Understanding Verbalizes Understanding Generated 071302019 14:05 by MD Bureau of Prisons - NYM SDNY_0001161 3 of 3 EFTA00138998 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 11:12 Provider: MD Reg #: 76318-054 Facility: NYM Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT PATIE ALS STAT HE DEN SPEAKING HE REPORT HE REPORTS TOPROL. HE AHS A HX OF SLEEP ISNCE HE HASB EEN INFORME DHIM THAT WE HIM TONIGHT.. HE REPORT OTHER NON-ME STATES HE FEELS OTHERWISE Pain: Not Applicable MD REFERRED BY THE WARDEN FOR EVALUATION. RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY OWING. IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING AND STATED HE HAS NOT SLEPT FOR 3 WEEKS E HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I HIS CPAP MACHINE AND IT WILL BE GIVEN TO ES. Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology0 Respiratory 0 OBJECTIVE: Pulse: Date lime Rate Per Minute Location 07/30/2019 13:02 94 07/30/2019 09:40 88 Via Machine 07/30/2019 09:30 87 Via Machine Respirations: Date Time 07/30/2019 09:30 NYM Rate Per Minute Provider 12 Blood Pressure: Data lime Value Location Position 07/30/2019 13:02 NYM 114/84 Left Arm Standing 07/30/2019 09:40 NYM 125/60 Right Arm Standing 07/30/2019 09:30 NYM 108/86 Left Arm Sitting SaO2: Data lima 07/30/2019 09:30 NYM Weight: Date Time Cuff Size Provider Value(%) Air Provider 98 Room Air Lin Kg Waist Circum. Provider MD MD MD MD MD MD MD Generated 071302019 14:05 by MD Bureau of Prisons - NYM SDNY_0001-7382 rage-1 of 3 EFTA00138999 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Encounter Date: 07/30/2019 11:12 Provider: M Race: WHITE Reg #: 76318-054 Facility: NYM MD Unit: Z01 Date Time 07/30/2019 09:30 NYM 194.2 88.1 MD Lbs Kg Waist Circum. Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distr ed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unk cutely III Nutrition No: Appears O Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR No: M/R/G Musculoskeletal Tibia / Fibula No: Edema Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0.27.9, adult, Z6827 - Current Constipation, unspecified, K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, 87303 - Current Sleep apnea, G4730 - Current 1 and S2 PLAN: New Medication Orders: Hxg Medication Order Date Prescriber Order Generated 07/3012019 14:05 by MD Bureau of Prisons - NYM SDNY_0001-7383 rage 2 of 3 EFTA00139000 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 11:12 Provider: MD Reg #: 76318-054 Facility: NYM Unit: Z01 New Medication Orders: fiat Medication Order Date Magnesium Hydroxide Susp conc 800 07/30/2019 11:12 MG/5ML Indication: Constipation, unspecified INsulin REG - Human 07/30/2019 11:12 Indication: Renew Medication Orders: 13att Medication 121836-NYM methylP Pack) Indication: New Laboratory Requests: Details Frequency Lab Tests - Short List-General-CBC w diff one Time Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short List-General•Comprehensiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic New Radiology Request Orders: Details General Radiology -Spine / Cervical- General Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NU PLEASE PERFORM C SPINE SERIES Prediabetes Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format 07/30/2019 Counseling 07/30/2019 Counseling Copay Required:No Telephone/Verbal Order: No Completed by ne 4 MG Tab ( 21 count Order Date 07/30/2019 11:12 a and neuritis, unspecified Frequency One Time Handout/Topic Access to Care Plan of Care Cosign Required: No MD on 07/30/2019 14:05 Prescriber Order 10 CC Orally • Two Times a Day PRN x 90 day(s) SLIDING SCALE Subcutaneously • Two Times a Day x 7 day(s) Pill Line Only Prescriber Order Take the tablet by mouth as directed x 6 day(s) Due Date 08/01/2019 00:00 Due Date 08/29/2019 Priority Routine Priority Routine R 2-3 MINUTES 3 DAYS AGO. Outcome Verbalizes Understanding Verbalizes Understanding Generated 072302019 14:05 by MD Bureau of Prisons - NYM SDNY_000a 3 of 3 EFTA00139001 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 15:58 Facility: NYM Amendment made to this note by MD on 07 30 2019 16:12. Bureau of Prisons • NYM SDNY_00017365 EFTA00139002 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/28/2019 20:25 Provider: RN Unit: H01 Nursing - Follow up encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: RN Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies) Subjective: Inmate seen for F/U after returning from attorney conference offers no new complaints or worsening S/S stats " My R hand still has pins and needles sometimes" No change in appearance from previous exam. Pain: No OBJECTIVE: Pulse: Date lime Rate Per Minute Location Rhythm Provider 07/28/2019 20:28 81 RN Respirations: Dale Time Rate Per Minute Provider 07/28/2019 20:28 NYM 14 RN Blood Pressure: Date lime Value Location Position Cuff Size Provider 07/28/2019 20:28 NYM 157/91 RN SaO2: Dale BEM Valuer/O1 Air Provider 07/28/2019 20:28 NYM 98 RN Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 Nutrition Yes: Within Normal Limits Skin General Yes: Within Normal Limits, Dry, Skin Intact ASSESSMENT: No Significant Findings/No Apparent Distress PLAN: Disposition: To be Evaluated by Provider Generated 07/28/2019 20:30 by RN Bureau of Prisons - NYM SDNY_000W1 of 2 EFTA00139003 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/28/2019 20:25 Provider: RN Unit: H01 Follow-up in 12-24 Hours Patient Education Topics: Date Initiated Format Handout/Topic 07/28/2019 Counseling Plan of Care Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Completed by RN on 07'28'2019 20:30 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Provider Outcome Verbalizes Understanding Generated 0712&201920:30 by RN Bureau of Prisons - NYM SDNY_0001-7387 rage 2 of 2 EFTA00139004 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/28/2019 20:25 Provider: RN Facility: NYM Cosigned by MD on 07 28 2019 20:50. ' Pr ',or, NYt! SDNV_00017368 EFTA00139005 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: RN Unit: H01 Nursing - Triage Note encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: RN Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies) Subjective: " I woke up and I had no control over my Right arm for a few minutes it was just doing what it wanted to do" Pain: No OBJECTIVE: Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/28/2019 06:57 82 RN Respirations: Date Time Rate Per Minute Provider 07/28/2019 06:57 NYM 14 RN Blood Pressure: Date lime Value Location Position Cuff Size Provider 07/28/2019 06:57 NYM 138/80 SaO2: Date Time Valuerkl Air 07/28/2019 06:57 NYM 98 Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 Skin General Yes: Within Normal Limits, Dry, Skin Intact provider Head General Yes: Symmetry of Motor Function, Atraumatic/Normocephalic No: Facial Asymmetry, Battle's Sign, Raccoon Eyes, Deformity Eyes General Yes: PERRLA, Extraocular Movements Intact RN RN Face General Yes: Symmetric Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM SDNY_00011491 of 3 EFTA00139006 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: RN Unit: H01 Exam: No: Ecchymosis, Numbness, Swelling, Periorbital Edema Neck General Yes: Abrasion(s) Pulmonary Observation/Inspection Yes: Within Normal Limits No: Respiratory Distress, Tachypnea, Hyperventilation Cardiovascular Observation Yes: Normal Rate Musculoskeletal Shoulder Yes: Full Range of Motion R, Symmetric R No: Swelling R, Inflammation R Humerus Yes: Within Normal Limits R Elbow Yes: Normal Exam R, Full Range of Motion R, Non-Tender on Palpation R Radius / Ulna Yes: Normal Exam R, Full Range of Motion R WrisVHand/Fingers Yes: Full Range of Motion R, Non-Tender on Palpation R, Swelling R No: Inflammation R, Ecchymosis R, Erythema R, Tenderness R, Laceration(s) R, Abrasion(s) R, Contusion(s) R ROS Comments Received inmate AAOX3 in no acute distress, speaking in full sentenced ambulating independently CIO Right arm numbness after waking up from "sleeping on my side" that has since subsided. inmate interviewed in psyc obs through the slot. V/S noted WNL, RR even and unlabored, no neurological deficits noted, no facial droop slurred speech or dysphagia, Inmate with Full ROM to all extremities with 4/4 strength bilaterally, slight swelling noted to right phalanges when compared to left, no edema, erythema or ecchymosis noted. Denies any pain numbness or tingling at this time. Denies any Chest pain, Headache, Dizziness, SOB or Blurred vision. Eyes PERRLA. MD on Call notified, Re-evaluate this evening or sooner if S/S persist. ASSESSMENT: Alteration in comfort PLAN: Disposition: Follow-up at Sick Call as Needed Notify Medical Duty Officer Patient Education Topics: Date Initiated Format Handout/Topic Provider Outcome 07/28/2019 Counseling Plan of Care Verbalizes Understanding Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM SDNY_0001 :7422 of 3 EFTA00139007 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: RN Unit: H01 Date Initiated Format HandouUTqpic Provider Outcome Copay Required:No Telephone/Verbal Order: No Completed by RN on 07/28/2019 07:22 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Cosign Required: Yes Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM SDNY_000'1 :7413 of 3 EFTA00139008 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/28/2019 06:51 Provider: RN Facility: NYM Cosigned by MD on 07.28.2019 20:51. ' Pr sae; NYt.' SDNV_00017372 EFTA00139009 Copay Required:No Telephone/Verbal Order: No Completed by Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: Date of Birth: Note Date: EPSTEIN. JEFFREY EDWARD 01/20/1953 07/26/2019 08:57 Sex: Provider: M MD Reg #: Facility: Unit: 76318-054 NYM H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. New Medication Orders: SX Medication Docusate Sodium Capsule Indication: Constipation, unspecified Cosign Required: No MD on 07/26/2019 08:58 Order Date 07/26/2019 08:57 Prescriber Order TAKE ONE 100 MG CAP Orally - Two Times a Day x 180 day(s) Generated 07.262019 08:58 by MD Bureau of Prisons - NYM SDNY_OOPOW1)3°I EFTA00139010 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: • Facility: NYM Note Date: 07/24/2019 16:10 Provider: MD Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. Copay Required:No Telephone/Verbal Order: Completed by Cosign Required: No 24/2019 16:12 Generated 07/24/2919 16:12 by MD Bureau of Prisons - NYM soNcooPoiVe EFTA00139011 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Rarp.WHITF Note Date: 07/24/2019 16:10 Provider: Reg #: 76318-054 Facility: NYM MD Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. Copay Required:No TelephoneNerbal Order: Completed by I Cosign Required: No 24/2019 16:12 Generated 07/24/2919 16:12 by MD Bureau of Prisons - NYM SDNY_OOPOWef 1 EFTA00139012 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/26/2019 08:57 Facility: NYM Amendment made to this note by MD on 07 26 2019 08:58. Bureau of Prisons • Nym SDNY_00017376 EFTA00139013 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Facility: NYM Note Date: 07/24/2019 15:10 Provider: 1WISM MD Unit: H01 Admin Note - General Administrative Note encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD PATIENT WAS OFFERED TO HAVE AN OPTOMETRIST EVALUATION. HE REFUSED. REFUSAL FORM SIGNED. Copay Required:No TelephoneNerbal Order: No Completed by Cosign Required: No MD on 07/24/2019 15:17 Generated 07/24/2919 15:17 by MD Bureau of Prisons - NYM SDNY_OOPOWV7°f 1 EFTA00139014 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/24/2019 13:08 Provider: MLP Unit: H01 Mid Level Provider - Follow up Visit encounter performed at Receiving & Discharge. SUBJECTIVE: COMPLAINT 1 Provider: . MLP Chief Complaint: Other Problem Subjective: I still do not want to talk about. But, between you and me. I think my room mate had to do with what happened to me. Do not ask me. I am not going to say anything. Pain: No OBJECTIVE: Temperature: Date Time Fahrenheit Celsius Location Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral MLP Pulse: Dale Time Rate Per Minute Location Rhythm Provider 07/24/2019 13:12 83 Via Machine Regular . MLP Blood Pressure: Date Time Maim Location Position Cuff Size Provider 07/24/2019 13:12 NYM 132/89 Right Arm Sitting Adult-regular MLP SaO2: Date Time Value(%) Ai_► Provider 07/24/2019 13:12 NYM 96 Room Air MLP Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Appears in Pain Exam Comments Follow up evaluation done for inmate Epstein. He does not look in any pain or distress. He still has the erythema around his neck. Central part of this erythema has some abrasion. Patient does not complaint of any respiratory problem or distress. He still does not want to explain how the skin injury on his neck happed. he insinuates that injuries on his neck have to do with his room mate. But does not want to talk about it. ASSESSMENT: Injury, unspecified, T1490 - Current PLAN: Disposition: Generated 07/24/2019 13:24 by MLP Bureau of Prisons - NYM SDNY_0001-7379 raya 1 of 2 EFTA00139015 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/24/2019 13:08 Provider: . MLP Unit: H01 Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format Handout/Topic ii. Outcome 07/24/2019 Counseling Access to Care . Verbalizes Understanding 07/24/2019 Counseling Preventive Health Verbalizes Understanding Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Completed by . MLP on 07/24/2019 13:24 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. SDNY Generated 07124/2019 13:24 by _0001-7379 MLP Bureau of Prisons - NYM raga 92 of 2 EFTA00139016 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/24/2019 13:08 Provider: MLP Facility: NYM Cosigned with New Encounter Note by MD on 07/24/2019 16:10. Bureau of Prisons NYM SDNY_00017380 EFTA00139017 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: MLP Unit: H01 Injury Assessment - Non-work related encounter performed at Health Services. SUBJECTIVE: INJURY 1 Provider: MLP Date of Injury: 07/23/2019 01:27 Date Reported for Treatment: 07/23/2019 08:25 Work Related: No Work Assignment: UNASSG Pain Location: Pain Scale: 0 Pain Qualities: Where Did Injury Happen (Be specific as to location): Special Housing Unit Z05-Cell 124 L Cause of Injury (Inmate's Statement of how injury occurred): "I do not know. Just went to drink a little water and wake up snorting". Symptoms (as reported by inmate): None OBJECTIVE: Temperature: Data Time Fahrenheit Celsius Location 07/23/2019 06:30 NYM 97.5 36.4 Oral Provider MLP Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/23/2019 06:30 92 Via Machine Regular . MLP Respirations: Data Time Rate Per Minute Provider 07/23/2019 06:30 NYM 16 MLP Blood Pressure: Data Time Value Location Position Cuff Size Provider 07/23/2019 06:30 NYM 140/85 Right Arm Sitting Adult-regular MLP SaO2: Date Time Value(%) Air Provider 07/23/2019 06:30 NYM 96 Room Air MLP Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Lethargic, Dyspneic, Appears in Pain, Pallor, Cyanotic, Diaphoretic, Disheveled, Generated 071231201909:05 by MLP Bureau of Prisons - NYM SDNY_0001-7391 raga 1 of 2 EFTA00139018 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: . MLP Unit: H01 Exam: Acutely III Pulmonary Auscultation Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally No: Crackles, Rhonchi, Wheezing Exam Comments Inmate for injury report as requested by Operational Lt. He is ambulatory, oriented x 3. In not apparent distress, smiling during this clinical encounter. Alleges, that he does not know what happened. Can not explain the marks on his neck. Responded: "I don't know". He does not want to talk of the events leading to the marks on his neck. He does not look in any distress or pain. Has an circular line of erythema at the base of the neck. Reaching 2/3 of the neck circumference, 2 inches wide, sparing the back of the neck. Has one section of this erythema in the front with marks of friction. No inflammation, no deformities, no hematomas, no lacerations, no tenderness. Patient moving his neck without any restriction. Denies having any pain or discomfort. Denies any respiratory problem. Has another small erythema on left knee about 2cm in diameter(mild). As per information from custody staff inmate Epstein was found in his cell with a rope around his neck and sitting on the floor. Inmate is currently placed on suicide watch. ASSESSMENT: Injury, unspecified, T1490 - Current - R/O self inflicted injuries. PLAN: Disposition: Follow-up at Sick Call as Needed Placed on Suicide Watch Follow-up in 2-4 Hours Other: For follow up with psychology service. Patient Education Topics: Date Initiated Format Handout/Topic MI. Outcome 07/23/2019 Counseling Access to Care Verbalizes Understanding 07/23/2019 Counseling Plan of Care Verbalizes Understanding Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Completed by . MLP on 07/23/2019 09:05 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 07123 201909.05 by MLP Bureau of Prisons - NYM SDNY_0001-739 ag2 re-2 of 2 EFTA00139019 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/23/2019 06:20 Provider: MLP Facility: NYM Cosigned by MD on 07/23/2019 15:44. Bureau of Prisons NYM SDNY_00017383 EFTA00139020 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/14/2019 17:36 Provider: MD Unit: Z05 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: MD Chief Complaint: ENDO/LIPID Subjective: 66 YR OLD WHITE MALE WITH HX OF HYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , NOW 431. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS DUE TO THEIR GI SIDE EFFECTS. HX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE FBI LOKELY HAS L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES. SURGICAL HX: NONE MENTAL HEALTH HX: NONE Pain: Yes Pain Assessment Date: 07/12/2019 13:25 Location: Back-Middle Quality of Pain: Shooting Pain Scale: 5 Intervention: MEDROL DOSE PACK Trauma Date/Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: Seen for clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid Added to clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid OBJECTIVE: Exam: General Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely III Nutrition No: Appears Obese Generated 07/14/2019 18:11 by MD Bureau of Prisons - NYM SDNY_00011464 1 of 3 EFTA00139021 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Arilivr/lHITE Encounter Date: 07/14/2019 17:36 Provider: MD Reg #: 76318-054 Facility: NYM Unit: Z05 Exam: Eyes General Yes: PERRLA, Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR), Normal St and S2 No: M/R/G Abdomen Auscultation Yes: Normo-Active Bowel Sounds Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back Yes: Tenderness Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam ASSESSMENT: Constipation, unspecified, K5900 - Current Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: JIM Medication Omega 3 ( Vascepa) 1 GM Capsule Order Date 07/14/2019 17:36 Indication: Hyperlipidemia, unspecified New Laboratory Requests: Details Frequency Lab Tests-H-Hemoglobin A1C One Time Lab Tests-L-Lipid Profile Additional Information: Generated 07/14;2019 18:11 by MD Bureau of Prisons - NYM Prescriber Order TAKE 2 CAPS Orally - Two Times a Day x 180 day(s) -- TAKE WITH FOOD. Due Date Priority 10/10/2019 00:00 Routine SDNY_00047 rog18852 of 3 EFTA00139022 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: Reg #: Facility: 76318-054 NYM Encounter Date: 07/14/2019 17:36 Provider: MD Unit: 205 FASTING. Lab Tests-H-Hep B surface Ab One Time 08/08/2019 00:00 Routine Lab Tests-H-Hep B surface Ag Lab Tests-H-Hep C Ab Lab Tests-H-Hepatic Profile Schedule: Activity Date Scheduled Clinical Encounter 07/24/2019 00:00 66 YR OLD MALE FOR ROUTINE SCREENING. Chronic Care Visit 01/07/2020 00:00 6 MONTH F/U. Chronic Care Visit 07/01/2020 00:00 Other: PENDING EKG AND FOBT. CXR WAS REFUSED. Patient Education Topics: Date Initiated Format 07/14/2019 Counseling Copay Required:No Telephone/Verbal Order: No Completed by Handout/Topic Diagnosis Cosign Required: No MD on 07/14/2019 18:11 Scheduled Provider Optometrist Mid-Level Provider Physician 01 Provider Outcome Verbalizes Understanding Generated 07/14/2019 18:11 by MD Bureau of Prisons - NYM SDNY_000R19 3 of 3 EFTA00139023 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: Z05 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDO/LIPID Subjective: 66 YR O HITE MALE WITH HX OF HYPER CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MED • EIR GI SIDE EFFECTS. HX OF 4L UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES TH Y HAS L4 - L5 SEVERE iSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREM SURGICAL HX: NONE MENTAL HEALTH HX: Pain: Yes Pain Assessment Date: 07/12/2019 13:25 Location: Back-Middle Quality of Pain: Shooting Pain Scale: 5 Intervention: MEDROL DOSE PACK Trauma Date/Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: MD Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology OBJECTIVE: Exam: General Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely III Nutrition No: Appears Obese Generated 07/12/2019 14:20 by MD Bureau of Prisons - NYM SDNY_0001-7187 raga 1 of 3 EFTA00139024 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: Z05 Exam: Eyes General Yes: PERRLA, Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal SI and S2 No: M/R/G Abdomen Auscultation Yes: Normo-Active Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back Yes: Tenderness Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General ASSESSMENT: Constipation, unspecified, 1(5900 - Current (N )Yes: Normal Exam Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: Mit Medication Order Date Prescriber Order Magnesium Hydroxide Susp 07/12/2019 13:10 30 CC Orally - Two Times a Day PRN x 2 day(s) Indication: Constipation, unspecified MethyIPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 AS DIRECTED Orally - daily x Pack 21 tab) 6 day(s) Indication: Neuralgia and neuritis, unspecified Disposition: Generated 07/1232019 14:20 by MD Bureau of Prisons - NYM SDNY_00047308 rage 2 of 3 EFTA00139025 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: Z05 Follow-up at Sick Call as Needed Other: WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP. Patient Education Topics: Date Initiated Format Handout/Topic 07/12/2019 Counseling Diagnosis Copay Required:No Telephone/Verbal Order: Completed by Beaudouin, Cosign Required: No 07/12/2019 14:20 0 Provider Outcome Verbalizes Understanding Generated 07/1232019 14:20 by MD Bureau of Prisons - NYM SDNY_000149 3 of 3 EFTA00139026 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: Z05 Chronic Care - 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDO/LIPID Subjective: 66 YR O HITE MALE WITH HX OF HYPER CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MED • EIR GI SIDE EFFECTS. HX OF UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES TH Y HAS L4 - L5 SEVERE iSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREM SURGICAL HX: NONE MENTAL HEALTH HX: Pain: Yes Pain Assessment Date: 07/12/2019 13:25 Location: Back-Middle Quality of Pain: Shooting Pain Scale: 5 Intervention: MEDROL DOSE PACK Trauma Date/Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: MD Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology OBJECTIVE: Exam: General Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt, Acutely III Nutrition No: Appears Obese of 3 Generated 07/12/2019 14:20 by MD Bureau of Prisons - NYM SONY_00011499 EFTA00139027 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: Z05 Exam: Eyes General Yes: PERRLA, Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal SI and S2 No: M/R/G Abdomen Auscultation Yes: Normo-Active Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back Yes: Tenderness Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam ASSESSMENT: Constipation, unspecified, K5900 - Current 421%0 Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current 1), Sleep apnea, G4730 - Current PLAN: New Medication Orders: Eta Medication Order Date Prescriber Order Magnesium Hydroxide Susp 07/12/2019 13:10 30 CC Orally - Two Times a Day PRN x 2 day(s) Indication: Constipation, unspecified MethyIPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 AS DIRECTED Orally - daily x Pack 21 tab) 6 day(s) Indication: Neuralgia and neuritis, unspecified Disposition: Generaled 07/1212019 14:20 by MD Bureau of Prisons - NYM SDNY_0001-739:1 rage 2 of 3 EFTA00139028 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: MD Unit: Z05 Follow-up at Sick Call as Needed Other: WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP. Patient Education Topics: Date Initiated Format Handout/Topic 07/12/2019 Counseling Diagnosis Copay Required:No Telephone/Verbal Order: Completed by Beaudouin, Cosign Required: No 07/12/2019 14:20 co Provider Outcome Verbalizes Understanding Generated 07/12/2019 14:20 by MD Bureau of Prisons - NYM SDNY_0001 :703 of 3 EFTA00139029 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/14/2019 17:36 Facility: NYM Amendment made to this note by MD on 07/142019 18:11. Bureau of Prisons • NYM SDNY_00017393 EFTA00139030 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: Date of Birth: Note Date: EPSTEIN, JEFFREY EDWARD 01/20/1953 07/12/2019 09:06 Sex: Provider: 1 MD Reg #: Facility: Unit: 76318-054 NYM Z05 Admin Note - Orders encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD PATIENT REQUESTED TO HAVE A COLACE RX , INSTEAD OF TEH BISACODYL FOR CONSTIPATION. New Medication Orders: 13x# Medication Docusate Sodium Capsule Indication: Constipation, unspecified Discontinued Medication Orders: I324 Medication 121757-NYM Bisacodyl E.C. 5 MG TAB Order Date 07/12/2019 09:06 Order Date 07/12/2019 09:06 Discontinue Type: When Pharmacy Processes Discontinue Reason:discontinue Indication: Copay Required:No TelephoneNerbal Order: No Completed by Cosign Required: No MD on 07/12/2019 09:10 Prescriber Order TAKE ONE 100 MG CAP Orally - Two Times a Day x 30 day(s) Prescriber Order Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10 days Generated 07/12/2919 09:10 by MD Bureau of Prisons - NYM soNy_ooPoicIld4' 1 EFTA00139031 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Facility: NYM Note Date: 07/07/2019 00:17 Provider: 1 MD Unit: E06 Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MED CL:1 NO CCC APPT. MD Discontinued Laboratory Requests: Details Frequency Due Date Priority Lab Tests-H-Hemoglobin AlC One Time 08/05/2019 00:00 Routine Lab Tests-C-CBC w/diff Lab Tests-E.-Lipid Profile Lab Tests-C-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic Additional Information: 66 y/o male, elevated BP Labs requested to be reviewed by: MD New Laboratory Requests: !Malls Frequency Due Date Priority Chronic Care Clinics-Diabetic-CBC w/diff One Time 07/25/2019 00:00 Routine Chronic Care Clinics-Diabetic-Lipid Profile Chronic Care Clinics-Diabetic-Hemoglobin A1C Lab Tests-H-HIV 1/2 Lab Tests-R-RPR Chronic Care Clinics-Diabetic-Comprehensive Metabolic Profile (CMP) New Radiology Request Orders: Details Frequency End Date Due Date Priority General Radiology -Chest-2 Views One Time 07/25/2019 Routine Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR. Copay Required:No TelephoneNerbal Order: No Completed by Cosign Required: No MD on 07/07/2019 00:30 Generated 07/07/2019 00:30 by MD Bureau of Prisons - NYM soNv_ooPoi9M? 1 EFTA00139032 Bureau of Prisons Health Services Health Screen Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Seizures: Denied Diabetes: Denied Cardiovascular: Denied CVA: Denied Hypertension: Denied Respiratory: Denied Sickle Cell Anemia: Denied Carcinoma/Lymphoma: Denied Allergies: Denied PPD Administration: Date/Time: 07/06/2019 21:39 Provider: PA-C Location: Right Forearm Drug Mfg: Sanofi Pasteur Lot Number: C5474BA Dosage: 0.1mL Route: ID Exp Dt: 10/2020 Comments: Tuberculosis: Hx of Previous Disease: No Blood-tinged Sputum: No Night Sweats: No Weight Loss:No Fever: No Cough:No Comments: Generated 07/06/2019 21:56 by PA-C Bureau of Prisons - NYM SDNY _00017396 'Page 1 of 6 EFTA00139033 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Infectious Disease Risk Factors: IV Drug Use: No IV Drug Use Needles: Sexual Partner IV Drug Use: No Sexual Partner IV Drug Use Needles: Female Sexual Partners (Last 5 Yrs): 10+ Male Sexual Partners (Last 5 Yrs): 0 Condom Use: Sometimes Sexual Contact With HIV+ Individual: No Blood Product Transfusion: No Travel Outside US: Yes Tattoos: No Comments: Born in US High school diploma Banker Traveled to Paris x 3 weeks up until arrest No tattoos HIV History: When Tested: 2019 Test Result: Negative When Diagnosed AIDS: Last CD4: Comments: Hepatitis: Denied Other Infectious Diseases: Syphilis: No Syphilis Last Treatment: N/A Genital Warts: No Chlamydia: Yes Gonorrhea: No Herpes: No Chicken Pox: Yes Other: No Comments: Chlamydia in 2015, treated Chicken pox in childhood Abuse History: Denied Physical: No Emotional: No Sexual: No Comments: Denies Generated 07/06/2019 21:56 by PA-C Bureau of Prisons - NYM SONY _00017397 'Page 2 of 6 EFTA00139034 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Mental Health: Level of Consciousness: Alert and Oriented Psychomotor Activity: Normal General Appearance:Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal