EFTA00139342.pdf

Inmate Name: EPSTEIN JEFFREY EDWARD Reg #: 76318-054 Dale of Birth: Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: 1101 Thorax: Contour Normal:Yes Increased AP Diameter: No Asymmetrical Expansion:No Lungs Clear: Yes Wheezes: No Crackles: No Rhonchi: No Rales: No Accessory Muscle Use: No Comments: Spine: Deformity: No Full ROM:Yes Tenderness: No Comments: Cardiovascular: RRR: Yes Normal St/S2: Yes Murmurs: No Carotid Bruits:No JVD: No Arteries: Bight Left Radial: Femoral: Dorsalis Pedis: Post. Tibialis: Comments: Generated 07/09/2019 13:03 by =E. MLP Bureau of Prisons - NVM Page 10 of 13 CONFIDENTIAL SDNY_00009437 EFTA00139342 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: H01 Abdomen: Normal Contour:Yes Scaphoid: No Obese: No Gravid: No Hernias: No Bruits: No Masses:No Scars: No Tenderness: No Organomegaly: No Active Bowel Sounds: Yes Comments: Extremities: Nails Clubbing: No Nails Cyanosis: No Lower Extremity Edema - Right: None Lower Extremity Edema - Left: None Atrophy: No Amputations: No Other Deformities: No Varicosities:No Calf Tenderness: No Pulse Deficit: No Strength: Sight Lett Arm: Leg: Full ROM: flight Lett Arm: Yes Yes Leg: Yes Yes Comments: Generated 07/0912019 13.03 by =M. MLP Bureau of Prisons - NYM Page 11 of 13 CONFIDENTIAL SDNY_00009438 EFTA00139343 Inmate Name: EPSTEIN JEFFREY EDWARD Reg #: 76318-054 Date of Birth: Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider. MLP Unit: H01 Reflexes: Right Left Biceps: Patellar: Brachioradialis: Achilles: Sensation: Vibratory: Yes Light Touch: Yes Pin Prick: Yes Comments: GU: Chaperoned By: Rectum: Not Done Comments: Refused. Male Genitalia: Not Done Comments: Refused. Skin: Normal: Yes Rash: No Redness:No Abnormal Pigmentation: No Abnormal Lesions/Growths: No Comments: Lymphatics: Adenopathy: No Comments: Potential Items For Follow-up: Travel Outside US Other Infectious Disease History Rectum Not Done Male Genitalia Not Done PPD Administration Not Performed Comments: Patient has a history of constipation. Generated 07/09/2019 13:03 by S MLR Bureau of Prisons-NYM Page 12d 13 CONFIDENTIAL SDNY_00009439 EFTA00139344 Inmate Name: EPSTEIN JEFFREY EDWARD Reg #: 76318-054 Date of Birth: Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: MLP Unit: H01 Cleared For Food Services: Yes Health Problems Newly Identified During This Encounter: Health Problem Constipation, unspecified - Current - New Medication Orders: Rxit Medication Order Date Prescriber Order Bisacodyl E.C. Tablet 07/09/201912:35 5 mg Orally at bedtime PRN x 10 day(s) Indication: Constipation, unspecified Disposition: Follow-up at Sick Call as Needed Instructed inmate how to obtain medical, dental, and mental health care. Copay Required: No Cosign Required: Yes TelephoneNerbal Order: No Completed by . MLP on 07/09/2019 13:03 Requested to be cosigned by MD. Cosign documentation will be displayed on the following page. Generated 07/09/2019 13:03 by MLP Bureau of Prisons - NYM Page 13 of 13 CONFIDENTIAL SDNY_00009440 EFTA00139345  Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN JEFFREY EDWARD Reg #: 76318-054 Date of Birth: Sex: M Race: WHITE Encounter Date: 07/09/2019 12:35 Provider: MLP Facility: NYM Cosigned by MD on 07/11/2019 22:41. Bunssu of FMsons NYM CONFIDENTIAL SONY 00009441 EFTA00139346  Bureau of Prisons Health Services Inmate Local Hospital Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD SENSITIVE BUT UNCLASSIFIED — This information is confidential and must be appropriately safeguarded. Transfer To: Transfer Date: 08/10/2019 Health Problems Health Problem Status Hyperlipidemia, unspecified Current HYPERTRIGLYCERIDEMIA Sleep apnea Current Essential (primary) hypertension Current BY HX. Constipation, unspecified Current Low back pain Current Neuralgia and neuritis, unspecified Current No Diagnosis Current Prediabetes Current Injury, unspecified Current R/O self inflicted injuries. Body mass index (BMI) 27.0-27.9, adult Current Medications: All medications to be continued until evaluated by a physician unless otherwise indicated. Bolded drugs required for transport. Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take one capsule (100 MG) by mouth twice daily for 30 days Docusate Sodium 100 MG Cap Exp: 01/22/2020 SIG: Take one capsule (100 MG) twice daily by mouth with plenty of water Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML Exp: 10/28/2019 SIG: shake well take 10ml by mouth twice daily AS NEEDED Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by mouth with food OTCs: Listing of all known OTCs this inmate is currently taking. None Pending Appointments Data Time Activity provider 07/24/2019 00:00 Clinical Encounter Optometrist 01/07/2020 00:00 Chronic Care Visit Mid-Level Provider 07/01/2020 00:00 Chronic Care Visit Physician 01 07/09/2020 00:00 PPD Administration Nurse Pending Non-Medication Orders: Order Order Data Freauency Duration Details EKG 07/06/2019 One Time 66 y/o male Fecal Occult Blood 07/06/2019 One Time 3 different stools TB Clearance: Yes Last PPD Date: 07/09/2019 Induration: 0mm Last Chest X-Ray Date: Results: TB Treatment: Sx free for 30 days: Yes TB Follow-up Recommended: No Sickle Cell: Sickle Cell Trait/Disease: No Generated 08110/2019 07:00 by RN Bureau of Prisons - NYM Page 1 of 2 CONFIDENTIAL SDNY_00009442 EFTA00139347 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD SENSITIVE BUT UNCLASSIFIED — This information is confidential and must be appropriately safeguarded. Limitations/Restrictions/Diets: Cell: tower bunk — 10/09/2019 Cleared for Food Service: Yes Other diet restrictions: FISH ALLERGIES. -- 07/30/2020 Comments: Allergies No Known Allergies Devices / Equipment C-Pap Travel: Direct Travel: No Travel Restrictions: None UNIVERSAL PRECAUTIONS OBSERVED WHEN TRANSPORTING ANY INMATE: Transfer From Institution: NEW YORK MCC Phone Number: 6468366300 Address 1: 150 PARK ROW Address 2: City/State/Zip: NEW YORK, New York 10007 Name/Title of Person Completing Form: RN Date: 08/10/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 DOB: Sex: M Generated 08110/2019 07:00 by RN Bureau of Rims - NYM Page 2ot 2 CONFIDENTIAL SONY 00009443 EFTA00139348  Bureau of Prisons Health Services Vitals All Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Temperature: Rat Time Fahrenheit Celsius Location Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral a MLP Orig Entered: 07/24/2019 13:14 EST a. MLP 07/23/2019 06:30 NYM 97.5 36.4 Oral MLP Orig Entered: 07/23/2019 08:33 EST a. MLP 07/09/2019 12:49 NYM 97.3 36.3 Oral a MLP Orig Entered: 07/09/2019 12:51 EST MLP Pulse: Dan Time Rate Per Minute Location Rhythm Provider 07/30/2019 13:02 94 MD Orig Entered: 07/30/2019 13:04 EST MD 07/30/2019 09:40 88 Via Machine MD Orig Entered: 07/30/2019 13:04 EST MD 07/30/2019 09:30 87 Via Machine MD Orig Entered: 07/30/2019 12:59 EST MD 07/28/2019 20:28 81 RN Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 82 RN Orig Entered: 07/28/2019 06:58 EST RN 07/24/2019 13:12 83 Via Machine Regular MLP Orig Entered: 07/24/2019 13:14 EST . MLP 07/23/2019 06:30 92 Via Machine Regular MLP Orig Entered: 07/23/2019 08:33 EST MLP 07/09/2019 12:49 82 Via Machine Regular MLP Orig Entered: 07/09/2019 12:51 EST MLP Respirations: Dan Time Rate Per Minute provider 07/30/2019 09:30 NYM 12 MD Orig Entered: 07/30/2019 12:59 EST MD 07/28/2019 20:28 NYM 14 RN Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 NYM 14 RN Orig Entered: 07/28/2019 06:58 EST RN 07/23/2019 06:30 NYM TIM I MLP Orig Entered: 07/23/2019 08:33 EST . MLP 07/09/2019 12:49 NYM 16 MLP Orig Entered: 07/09/2019 12:51 EST MLP Generated 0811oriole 11:02 by Bureau of Prisons NYM Page 1 of 3 CONFIDENTIAL SDNY_00009444 EFTA00139349 Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318.054 Inmate Name: EPSTEIN, JEFFREY EDWARD Blood Pressure: age Time Value Location Position Cuff Size Provider 07/30/2019 13:02 NYM 114/84 Left Arm Standing MD Orig Entered: 07/30/2019 13:04 EST MD 07/30/2019 09:40 NYM 125/60 Right Arm Standing MD Orig Entered: 07/30/2019 13:04 EST MD 07/30/2019 09:30 NYM 108/86 Left Arm Sitting MD Orig Entered: 07/30/2019 12:59 EST MD 07/28/2019 20:28 NYM 157/91 RN Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 NYM 138/80 RN Orig Entered: 07/28/2019 06:58 EST RN 07/24/2019 13:12 NYM 132/89 Right Arm Sitting Adult-regular MLP Orig Entered: 07/24/2019 13:14 EST MLP 07/23/2019 06:30 NYM 140/85 Right Arm Sitting Adult-regular a MLP Orig Entered: 07/23/2019 08:33 EST MLP 07/09/2019 12:49 NYM 117/66 Right Arm Sitting Adult-regular MLP Orig Entered: 07/09/2019 12:51 EST MLP Blood Glucose: Date iT me Yalu_e_ftrigLdll IYRe Begukr Insulin Provider 08/04/2019 08:30 156 Non-Fasting RN Orig Entered: 08/04/2019 09:08 EST RN 08/02/2019 06:30 97 Non-Fasting MLP Orig Entered: 08/02/2019 08:16 EST a MLP 08/01/2019 06:30 103 Non-Fasting MLP Orig Entered: 08/01/2019 09:00 EST a. MLP 07/31/2019 06:15 108 Non-Fasting MLP Orig Entered: 07/31/2019 08:36 EST MLP SaO2: Date Time Value(%) Air Provider 07/30/2019 09:30 NYM 98 Room Air MD Orig Entered: 07/30/2019 12:59 EST MD 07/28/2019 20:28 NYM 98 RN Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 NYM 98 RN Orig Entered: 07/28/2019 06:58 EST RN 07/24/2019 13:12 NYM 96 Room Air MLP Orig Entered: 07/24/2019 13:14 EST MLP 07/23/2019 06:30 NYM 96 Room Air MLP Orig Entered: 07/23/2019 08:33 EST MLP 07/09/2019 12:49 NYM 97 Room Air MLP Orig Entered: 07/09/2019 12:51 EST MLP Height: Generated 08/1012019 11.02 by Bureau of Prisons NYM Page 2 of 3 CONFIDENTIAL SDNY_00009445 EFTA00139350 Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date Time Inches cm Provider 07/09/2019 12:49 NYM 70.0 177.8 la. MLP Orig Entered: 07/09/2019 12:51 EST a. MLP Weight: Q~g Time Mu Kg Waist Circum, provider 07/30/2019 09:30 NYM 194.2 88.1 MD Orig Entered: 07/30/2019 12:59 EST MD 07/09/2019 12:49 NYM 194.4 88.2 . MLP Orig Entered: 07/09/2019 12:51 EST MLP Generated 08110/2019 11:02 by Bureau of Prisons • NYM Page 3 of 3 CONFIDENTIAL SDNY_00009446 EFTA00139351  Bureau of Prisons Health Services PPDs Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Admixu Jscation Provider Reading• Jnduratioq Provider 07/06/2019 21:39 Right Forearm PA-C 07/09/2019 12:47 0 mm . MLP Orig Entered: 07/06/2019 21:43 EST PA-C Orig Entered: 07/09/2019 12:47 EST . MLP Total: 1 Generated 08/10/2019 11:02 by RN/10P/10C Bureau of Prisons • NYM Page 1 of 1 CONFIDENTIAL SDNY_00009447 EFTA00139352 76318.054 EPSTEIN. JEFFREY Medication Administration Record JULY 2019 Medication Orders Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Ord. Data MD 07/30/19 PRN 14:21 Inject regular Insulin subcutaneously per Exp. Dam sliding scale: Mice daily •"pIll line" for 7 07/31/19 days 10 01 NYM 122148- NYM Insulin Reg (10 ML) 100 UNITS/ML In) Ord. Dale Beaudown, Robert MD 07/31119 PRN 10:00 Inject regular insulin subcutaneously par Exp. Dale sliding scale: each morning for 7 days "'pin 08107/19 One"' 09:59 NYM 122160- NYM InsoLn Reg (10 ML) 100 UNITS/ML In; _ Providers: YJ = Documentation Codes: ORD = Order I NI = Dose Not Indicated Registration U. 76318-054 Pt Name. EPSTEIN, JEFFREY DOS: 01/20/53 Report information is current as 04 the date and time of printing. 08/10/2019 11:02 EST CONFIDENTIAL SDNY_00009448 EFTA00139353 76318.054 EPSTEIN, JEFFREY Medication Administration Record AUGUST 2019 Medication Orders Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Ord. Dale MD 07/31/19 PRN 10.00 Infect regular insulin subcutaneously per Exp. Dare sliding scale: each morning for 7 days —Mg 09/07/19 line— 09.59 NYM 122160- NYM Insulin Reg (10 ML) 100 UNITS/ML Inj Providers: YJ Documentation Codes: ORD = Order I NI = Dose Not Indicated Registration ft 76318-054 Pt. Name. EPSTEIN, JEFFREY 008: 01/20/53 Report information is current as of the dale and time of printing. 08/10/2019 11d2 EST CONFIDENTIAL SDNY_00009449 EFTA00139354  Bureau of Prisons Health Services Devices and Equipment Start Date: 07/07/2019 Stop Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Pevice/Eauioment Start Date Stoo Date Pate Returned Obtained From Comments C-Pap 07/30/2019 14:05 EST MD 07/30/2019 Personal PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Total: 1 Generated 08/1012019 11:02 by RN/1OPADC Bureau of Prbons NYM Page 1 of 1 CONFIDENTIAL SDNY_00009450 EFTA00139355  Bureau of Prisons Health Services Pain Management Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD QM Jnterventiort Pain Quality Location Pre Post Provider 07/12/2019 13:25 MEDROL DOSE PACK Shooting Back-Middle 5 MD Orig Entered: 07/12/2019 13:28 EST MD Generated 08/10/2019 11:02 by RNAOP/I0C Bureau of Prisons - NYM Page 1 of 1 CONFIDENTIAL SDNY_00009451 EFTA00139356  Bureau of Prisons Health Services Modified Diet Request Types of Diets: Clear Liquid Exp Date: Low Fat Exp Date: Mechanical Soft Exp Date: Low Cholesterol Exp Date: — Low Triglyceride Exp Date: _ Renal Exp Date: — Full Liquid Exp Date: — Sodium Controlled Exp Date: Snack Exp Date: Diabetic Exp Date: Calorie Controlled Exp Date: X Other: FISH ALLERGIES. Exp Date: 07/30/2020 Comments: MD Health Service Staff EPSTEIN, JEFFREY EDWARD 76318-054 07/30/2019 Inmate Name Reg# Date Generated 07730/2019 14:57 by MD Bureau of Prisons - NYM Page 1 of 1 CONFIDENTIAL SDNY_00009452 EFTA00139357  Bureau of Prisons Health Services Allergies Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Minn Date Noted Reaction No Known Allergies 07/06/2019 Orig Entered: 07/06/2019 21:40 EST PA-C Total: 1 Generated 08/10/2019 11:02 by Bureau of Prisons • NYM Page 1 of 1 CONFIDENTIAL SDNY_00009453 EFTA00139358  Bureau of Prisons Health Services Patient Education Assessments & Topics Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Assessments Assessment Learns Best By Primary Language Years of Education Barriers To Education Provider 07/09/2019 Speaking/Listening English 12 None Orig Entered: 07/09/2019 12:52 EST Total: 1 Topics Bate Initiated Format Handout/Tooic Outcome provider 07/30/2019 Counseling Access to Care Verbalizes Understanding Orig Entered: 07/30/2019 13:33 EST 07/30/2019 Counseling Plan of Care Verbalizes Understanding Orig Entered: 07/30/2019 13:34 EST 07/28/2019 Counseling Plan of Care Verbalizes Understanding OrIg Entered: 07/28/2019 07:22 EST 07/28/2019 Counseling Plan of Care Verbalizes Understanding Orig Entered: 07/28/2019 20:30 EST 07/24/2019 Counseling Access to Care Verbalizes Understanding Orig Entered: 07/24/2019 13:23 EST 07/24/2019 Counseling Preventive Health Verbalizes Understanding Orig Entered: 07/24/2019 13:23 EST 07/23/2019 Counseling Access to Care Verbalizes Understanding Orig Entered: 07/23/2019 09:04 EST 07/23/2019 Counseling Plan of Care Verbalizes Understanding Orig Entered: 07/23/2019 09:04 EST 07/14/2019 Counseling Diagnosis Verbalizes Understanding Orig Entered: 07/14/2019 18:11 EST 07/12/2019 Counseling Diagnosis Verbalizes Understanding Generated 08/10,2019 11:02 by RaltIOP/IDC Bureau of Prisons • NYM Page 1 of 2 CONFIDENTIAL SDNY_00009454 EFTA00139359  Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Topics Pate Initiated Format Handout/rot:4c Outcome Orig Entered: 07/12/2019 13:33 EST Total: 10 TOINE0NNO3 Generale0 08/10/2019 11:02 by RN/IOP/1OC Bureau of Prisons - NYM Page 2 of 2 95460000-MOS EFTA00139360  Bureau of Prisons Health Services Blood Glucose Begin Date: 07/07/2019 End Date: 08/10/2019 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD (Reference Range: Random or Fasting 70 - 100, 2 hour post-prandial 70 - 140) D.abit Time Value UPS Comments 08/04/2019 08:30 NYM 156 Non-Fasting Orig Entered: 08/04/2019 09:08 EST RN 08/02/2019 06:30 NYM 97 Non-Fasting Orig Entered: 08/02/2019 08:16 EST MLP 08/01/2019 06:30 NYM 103 Non-Fasting Orig Entered: 08/01/2019 09:00 EST MLP 07/31/2019 06:15 NYM 108 Non-Fasting Orig Entered: 07/31/2019 08:36 EST MLP Total: 4 Generated 08/10/2019 11:02 by RN/1OPADC Bureau of Pitons - NNW Page 1 of 1 CONFIDENTIAL SDNY_00009456 EFTA00139361  Bureau of Prisons Health Services Health Problems Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Description Axis Code TYDe Cada J)iag. Date Status Status Date Current Hyperlipidemia, unspecified 07/12/2019 13:48 EST MD ICD-10 E785 07/12/2019 Current HYPERTRIGLYCERIDEMIA Sleep apnea 07/12/2019 13:56 EST MD ICD-10 G4730 07/12/2019 Current Essential (primary) hypertension 07/30/2019 13:13 EST MD ICD-10 110 07/30/2019 Current BY HX. Constipation, unspecified 07/09/2019 12:58 EST MLP ICD-10 K5900 07/09/2019 Current Low back pain 07/12/2019 13:30 EST MD ICD-10 M545 07/12/2019 Current Neuralgia and neuritis, unspecified 07/12/2019 13:30 EST MD ICD-10 M792 07/12/2019 Current No Diagnosis 07/09/2019 10:28 EST PhD/Chief I DSM-IV No Dx 07/09/2019 Current Psychologist Prediabetes 07/30/2019 13:26 EST MD ICD-10 R7303 07/30/2019 Current Injury, unspecified 07/23/2019 09:04 EST . MLP 1CD-10 T1490 07/23/2019 Current R/O self inflicted injuries. Body mass index (BMI) 27.0-27.9, adult 07/30/2019 13:14 EST MD ICO-10 Z6827 07/30/2019 Current Total: 10 Generated 013/10/2019 11:02 by RN/1O13/1DC Bureau of Prisons - NYM Page 1 of 1 CONFIDENTIAL SDNY_00009457 EFTA00139362