EFTA00140162.pdf

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 slats " My R hand still has pins and needles sometimes" No change in appearance from previous exam. Pain: No OBJECTIVE: Pulse: Data lima Rate Per Minute ).oration Rhythm Provider 07/28/2019 20:28 81 RN Respirations: Data lima Rate Per Minute Provider 07/28/2019 20:28 NYM 14 RN Blood Pressure: Data ljDle Yaks Lasaiian Position Cuff Size Provider 07/28/2019 20:28 NYM 157/91 RN SaO2: Data lima Value(%1 Air provider 07/2812019 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 Generale: 07/28/2019 20:30 by RN Bureau of Prisons - NYM Page 1 of 2 EFTA00140162 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Ra : 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 Handoutropic Provider autagmft 07/28/2019 Counseling Plan of Care Verbalizes Understanding Copay Required: No Cosign Required: Yes TelephomWerbal Order: No Completed by i RN on 07/28/2019 20:30 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Gsnareled 07/28/2019 20:30 by RN Bureau of Prisons - NYM Pig* 2 of 2 EFTA00140163  Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg ti: 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. Bureau 01Prisons • NYM EFTA00140164  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: Delft Time Rine Per Minute .t,ocatiort Rhythm Provider 07/28/2019 06:57 82 RN Respirations: Daft Time Rate Per Minute Provider 07/28/2019 06:57 NYM 14 RN Blood Pressure: Pitt Time Value Location position Cuff Size Provider 07/28/2019 06:57 NYM 138/80 RN SaO2: Data Time ValuerAl Ai[ Provider 07/28/2019 06:57 NYM 98 RN Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 Skin General Yes: Within Normal Limits. Dry. Skin Intact Head General Yes: Symmetry of Motor Function, Atraumatic/Normocephalic No: Facial Asymmetry, Battle's Sign, Raccoon Eyes, Deformity Eyes General Yes: Extraocular Movements Intact Face General Yes: Symmetric Generated 07/28201907:22 by RN Bureau of Prisons • NYM Page 1 of 3 EFTA00140165 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 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 Wrist/Hand/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 NOS 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. 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 aiifitiumbness 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 Emmet Handout/Topic Outcome 07/28/2019 Counseling Plan of Care Verbalizes Understanding Gener*0 07/2812019 07:22 by RN Bureau of Prisons • NYM Page 2 of 3 EFTA00140166 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Dale: 07/28/2019 06:51 Provider: RN Unit: H01 Date Initialed Formal HandoutlTonic Provider Outcomq Copay Required:No Cosign Required: Yes ThlephoneNerbal 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. Generated 07/28/2019 0722 by RN Bureau or Prisons - NYM Page 3 of 3 EFTA00140167  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. Bureau of Prisons - NYM EFTA00140168  Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Facility: NYM Note Date: 07/26/2019 08:57 P SreoxVider: 1.1.11. MD Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MD THE MU' NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. New Medication Orders: Ed Medication Order Data 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 Cosign Required: No TelephoneNerbal Order No Completed by MD on 07/26/2019 08:58 Generated 01/26)2019 08:58 by MD Bureau of Prisons - NYM Page 1ot 1 EFTA00140169  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: 1 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 Cosign Required: No TelephoneNerbal Order: Completed by 2412019 16:12 0, Generated 07124/2019 1B12 by Bureau of Prisons - NYtd Page 1 of 1 EFTA00140170  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: M 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 Cosign Required: No TelephoneNerbal Order: Completed by 24/2019 16:12 41ji Generated 07/24/2019 16-17 by MD Bureau of Prisons - NYM Page 1 of 1 EFTA00140171  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 SAD on 07/26/2019 08:58. Bureau of Prisons • NYM EFTA00140172  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: all. 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 Cosign Required: No TelephoneNerbal Order: No Completed by MD on 07/24/2019 15:17 Generated 07/24/201915:17 by MD Bureau o Prisons - NYM Page 1of 1 EFTA00140173  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: Dale Time Fahrenheit Colony: Location Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral MLP Pulse: Pak Time Rate Per Minute Location Rhythm provider 07/24/2019 13:12 83 Via Machine Regular MLP Blood Pressure: j?ate Time Value t.ocatiort Position Cuff Size Provider 07/24/2019 13:12 NYM 132/89 Right Arm Sitting Adult-regular MLP SaO2: Data Time Valuead Ail 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 Liam 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 hopped. 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 Dumb of Prisons • N11/44 Page 1 of 2 EFTA00140174 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 Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated format Handout/Toolc Outcome 07/24/2019 Counseling Access to Care Verbalizes Understanding 07/24/2019 Counseling Preventive Health Verbalizes Understanding Copay Required:No Cosign Required: Yes TelephonelVerbal 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. Generator' 07124/2019 13:24 by Burn of Prisms • NYM Page 2 of 2 EFTA00140175  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 EFTA00140176  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 205-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: Da s Time Fahrenheit Celsius Location provider 07/23/2019 06:30 NYM 97.5 36.4 Oral MLP Pulse: Data Time Rate Per Minute Location. Rhythm Provider 07/23/2019 06:30 92 Via Machine Regular MLP Respirations: Date Time Rate Per Minute provider 07/23/2019 06:30 NYM 16 MLP Blood Pressure: Data Ems Value Location Position Cuff Size Provider 07/23/2019 06:30 NYM 140/85 Right Arm Sitting Adult-regular MLP SaO2: Data Time Valuer/al Ak 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 07/23/2019 09-.05 by MLP Bureau of Prisons • NYM Page 1 of 2 EFTA00140177 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg I& 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE 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 Dam Commentt 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: al 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: Pate Initiated &Ina Handout/Topic Provide( 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 TelephoneNerbal 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 0729/2019 0905 by MLP Bureau of Prisons NYM Page 2 of 2 EFTA00140178  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 07/23/201915:44. Bureau d Prisons - NYM EFTA00140179  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): OrthopedictRheumatology, Pulmonary/Respiratory, EndocrineAlpid 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 Page 1 of 3 EFTA00140180 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE NYM Encounter Date: 07/14/2019 17:36 Provider: MD 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: M/R/G Abdomen Auscultation Yes: Normo-Active Bowel Sounds Palpation Yes: Within Normal Limits Musculoskeletal Tibia I 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 Hypertipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: Ex/ Medication Order Date Prescriber Order Omega 3 ( Vascepa) 1 GM Capsule 07/14/2019 17:36 TAKE 2 CAPS Orally - Two Times a Day x 180 day(s) — TAKE WITH FOOD. Indication: Hyperlipidemia, unspecified New Laboratory Requests: Details Freauency p ue Date priority Lab Tests-H-Hemoglobin AIC One Time 10/10/2019 00:00 Routine Lab Tests-L-Lipid Profile Additional Information: GenorMed 07/14/2019 18:11 by MD Bureau of Prisons - NYM Page 2 of 3 EFTA00140181 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Binh: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/14/2019 17:36 Provider: MD Unit: Z05 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 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: Date Initiated Format flandout/Topic Outcome 07/14/2019 Counseling Diagnosis Verbalizes Understanding Copay Required: No Cosign Required: No TelephoneNerbal Order: No Completed by MD on 07/14/2019 18:11 Generated 07/14/2019 18:11 by MD Bureau ot Prisons NYM Page 3 of 3 EFTA00140182