EFTA00132684.pdf

90A-NY-3151227 Serial 98 FD-I036 (Rev. 10.162009) UNCLASSIFIED FEDERAL BUREAU OF INVESTIGATION Import Form Form Type: OTHER - Other Date: 09/06/2019 Title:(U) Medical Notes Regarding Jeffrey Epstein Approved By: SSA Drafted By: Case ID #: 90A-NY-3151227 (U) UNSUB(S); JEFFREY EPSTEIN - VICTIM; DEATH INVESTIGATION Synopsis: (U) On August 10, 2019, BOP SIS provided BOP medical notes regarding Jeffrey Epstein. ♦♦ UNCLASSIFIED EFTA00132684  COFRM BP-S35$.060 MEDICAL TREATMENT REFUSAL SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-20V Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Fefleral Bureau of Prisons Medical staff for the following conditIon(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. MD 7-24-2019 Counseled by Date Date NYU-NEW YORK MCC I. EFTA00132685  COFFINI BP-S358.050 • MEDICAL TREATMENT REFUSAL SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREA9 OF PRISONS 7-10-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: 66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR. The following treatment(s) wasfwere recommended: CHEST X-RAY Federal Bureau of Prisons Medical staff members have carefully explained to me that the( following possible consequences and/or complications may result because of my refusal to accept treatment: WORSENING THE CONDITION IF THERE IS ANY FINDINGS I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting,and following my expressed wishes and directions. 1.: -RAY 7-10-2019 Counse e y Date NYM-NEW YORK MCC Signature of Witness Date EFTA00132686  CDFRA4 BP.S358 060 MEDICAL TREATMENT REFUSAL SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF • RISONS 7-24-261 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the folio g possible consequences and/or complications may result because of my refusal to accept trea ent: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental c • ndition, and release the Bureau of Prisons and Its employees from any and all liability for respecting and •!lowing my expressed wishes and directions. MD 7-24-2019 Date Pa l's Sign Date Counseled by tlr NYM—NEW YORK MCC ate 5 /r -Cie EFTA00132687  A&O DENTAL EXAMINATION BP-A0618 (Initial Clinical Dental Findings) JUN 16 FEDERAL BUREAU OF PRISONS U.S. DEPARTMENT OF JUSTICE 0ral Hygiene: Good Fair CPITN: 3 3 Head & Neck / Soft Tissue: s 2- 9 16 5 rS 1 2 3 4 5 6 7 5 9 1011 1213 14 15 22 2120 10 • 18 17 C - 32 31 33 29 28 27 26252423 2 Ciass'dua0orc CL er Pain Scale: /10 Co 4 O 4,: ca ctf1Ctic, tekte Dental Prostheses at Intake: • Jr:5 / I,ica P eiwl Yes No R G2 SS i on Dip ~— I ils- 1° r O,..Acn or Ciryt.Q.-in 4 05-e-A f-4 Type: Ate: Condition: Intro-oral Photos Taken: Radiographs Takart (Document findings on MO encounter) Yes C Yea No . Instructed how le obtain urgent and non-urgent dental care Yes: I No: Na Non-urgent I Urgent Refiarld lo Sick Cal Treatment Priorities: non-urgent , . Yes I No Redxgraphs eutiorized: Prophylaxis authorized PAs: (Approval valid 18 months from examination date) BWc Pancrex Pa t Narne: Dentist S • nature: SI7C) 04 —3 —e_SIP-itti 5 Number: i Institution: / Date: SI nature Bin k/Stamp: -76 3 14% Os-1 MCC NEW YORK "7- 26 -i 9. . li ntet one (Juicer MCC New York Repair:IS 18 818.8110 P0F Proscnbed by P6403 EFTA00132688 BP-A0818 A&O DENTAL EXAMINATION (Initial Clinical Dental Findings) JUN 18 FEDERAL BUREAU OF PRISONS U.S. DEPARTMENT OF JUSTICE Occlusion: Good fat Pcor Oral Hygiene: • S 1 2 3 4 5 6 7 8 9 1011 1213 2 re 14 15 16 32 31 30 29 28 27 2825 24 23 22 21 20 is 18 17 CPITN: Head & Nook / Soft Tissue 3 Classification: 3 9 0 Pain Sortie: /O Comment,: I of yanCea. Dental Prostheses at Intake: t CP. 44n 1 )13 i lA t' l Yes Type: No rc.Ce SSi on 019 SeiV-e- Pl iPCI- Za-14_4- C.--401 cur Croyllinc 0.10.5euteed Age: Condtlon: Intra-oral Photos Taken: Radiographs Takerc (Document findings on A80 encounter) Yes Yes 0 3 . Yes: ti No: Instructed how to obtain urgent and non-urgent den& care: None: Non-urgent Urgent Referred to Sick Cal: Treatment Pricultes: non-urgent • Prophylaxis authorized: Yes' i No Radiographs autorfzed: PM: (Approval valid 18 months from examinaton data) 8Ws Panore:c nature: Pro Name: i Cc-Pit ti t-- Dentist Mtin i -3 — 16 173 Nurnber: I I (tIt US`{ Instttu tIon: / MCC NEW YORK —Date: 7- 24 -/ 9. Signature Block/Stamp: abimnamISDS. Chief en cer MCC New York • Proscribed by P6400 Replaces BP-A0616 c1JUN 10 PDF EFTA00132689  CDFR?. BP-S358 C60 MEDICAL TREATMENT REFUSAL SEP 05 FEDERAL BUREAU OF PRISONS U.S. DEPARTMENT OF JUSTICE /-24.2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental co dItIon, and release the Bureau of Prisons and its employees from any and all liability for respecting and f (lowing my expressed rections. 7-24-2019 Date Pa nt's Sign Date Counseled by NYM-NEW YORK MCC EFTA00132690  Federal U.S. Medical Center for Federal Prisons Bureau of 1900 W. Sunshine Street Prisons S nn field, MO 65807 ••• Sensitive But LiLlassified Name EPSTEIN, JEFFREY Facility MCC New York Collected 07/09/2019 13:34 Reg # 76318-054 Order Uniali m Received 07/10/201310:44 DOB 01/20/1953 Provider MD Reported 07/10/20 9 14:46 Sex M LIS ID 188191004 HIV HIV 1/2 Negative Negative Screening test - See confirmatory testing for Reactive results FLAG LEGEND L=Low LI=Low Critical H=High HI=High Critical A=Abnormal Al =Abnornial Critical Page 3 of 3 EFTA00132691  Bureau of Prisons Health Services Cosign/Review Reg #: 76,i18-054 Inmate Name: EPSTEIN, JEFFREY EDWARD 01/20/1953 Sex: M Race: WHITE Date of Birth: 16:58 Provider: Lab Result Receive Facility: NYM Ercounter Date: 07/10/2019 Cosigned by MD on 07/14/2019 18:12. bauelPikane-NYM EFTA00132692  CDFRM BP-S358.060 MEDICAL TREATMENT REFUSAL SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-20 9 Date I, JEFFREY EPSTEIN 76318-054 refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatments) was/were recommended: EYE DOCTOR EVALUATION. l Federal Bureau of Prisons Medical staff members have carefully explained to me that the following I possible consequences and/or complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse and recommended treatment. I hereby assume all responsibility for my physical and/or mental condiUon, release the Bureau of Prisons and Its employees from any and all liability for respecting and following my expressed •ns. 7-24-2019 Date Pa t's Sign- Date Counseled by NW-NEWYORKMCC EFTA00132693 BP-A0618 A&O DENTAL EXAMINATION JUN 18 (Initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Occlusion Mi Oral Hygtono: Good Fair ve " co CPITN: 3 3 3 2- 9 Head 8 Neck I Soft Tissi10: 1 2 3 4 6 8 7 0 9 1011 1213 14. 15 18 tn 313 29 28 27 28 25 24 23 22 21 20 19 • 18 17 21 E 32 31 Classification: D. 0 M: I F: Pain Scale: /14 :: 1 NN IM lift::(1\11)ke Denba Prostheses et Intact Comm 4 O ac t g it:15 aka Yes 1)4,13: SS/ on Di,Seiv-e-J• Rce Age: ConditioN Lootr c--.. Aci pc CayocLiAs 0109--M4 IMra-cral Photos Taken: Radiographs Talton: (Document findings on MO encounter) Yos Yos Si 0 Instructed how to obtain urgent and non-urgent dental cart Yes: I No: Treatnent Priori:los: None: Non-ingent Urgent Refonel to Sidc Cott non-urgent Radiographs au/lofted: Prophylaxis authorized; Yes i No PM: (Approval valid 18 months from examination data) BWs Panorex Pa t Name: Dentist Striatum: S'-' ..,; n i —3—C—C-R -Q- y E. i r Number: l Institution: / Date: Signature dr/Stamp: 7(2 3 ig- as-ki MCC NEVV YORK --7- 26 --/ 9. maLs. cntet oentai leer MCC New Vprk • PDF Presceeed by P8400 Rep/aces RP-A0818 of JUN 10 EFTA00132694  COFRM 8P-S358.060 MEDICAL TREATMENT REFUSAL SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept tree ent INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse and recommended treatment I hereby assume all responsibility for my physical and/or mental condition, release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed w ctlons. MD 7-24.2019 Counseled by Dale NYM-NEW YORK MCC Si ate 1 / 7 r d-Ct EFTA00132695  CDFRM BP-S388.C60 MEDICAL TREATMENT REFUSAL SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-10-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: 66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR. The following treatment(s) was/were recommended: CHEST X-RAY Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment: WORSENING THE CONDITION IF THERE IS ANY FINDINGS I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. X-RAY 7-10-2019 . Date Patien Date Counseled by NYM-NEW YORK MCC SIgnature of Witness Date EFTA00132696 BP-A0618 A&O DENTAL EXAMINATION JUN 16 (initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Occlusion: 2'r Oral Hygiene: Gocd Fat CPITN: 3 3 Fleael & Neck / Soft Tissue: 2- 9 1 2 3 4 5 6 7 6 0 10 11 12 13 14 15 16 S2 32 31 30 20 26 27 28 25 24 23 22 21 20 10 • 18 17 Classification: CC CL_ II O: 10 Illt F: / Pain Scale: /10 Firs: .17 ova / m I Iota Dental Prostheses at intake: Yes No Type: it ce SS/ on bi,SeitiLe, .14,--Xes- - C-'. Act( oar Calallini 49 SCA4 Age: Condition: Radiographs Taken: (Document n fi dings on A8.0 r) intia-oral Pholos Tama Yes Yes 9 0 Yes: 11 No: lastataed how to obtain urgent and non-urgent dental care: None: Non.urgent Urgent Referred to Sick Call: Treatment Prloges: non-urgent Ftadlographa authorized: - Prophylaxis authorized: Yes i No PM: (Approval valid 18 months from examination dale) BlNs: Panons.c Pa nt Name: Dentist ••, •, • S ' S Signature SloCk/Stamp: istfNumber: institution: / Date: --431 Sc- os -ki MCC NEW YORK 7- z€ -1 9. aChiet UentB tcer MCC New York Prescribed thf RICO Replaces BP.A0618 of JUN 10 PDF EFTA00132697  Bureau of Prisons Health Services Clinical Encounter Reg #: 76318-064 Inmate Name: EPSTEIN, JEFFREY EDWARD Fastlity: NYM Date of Birth: 01/20/1953 Sex: M Race: WHITE Provider: =RN Unit: Z04 Encounter Date: 08/10/2019 07:25 Unit. Emergency Code - Resuscitation Event encounter performed at Special Housing SUBJECTIVE: Emergency Note Provider. IIMI IIMIRN Team Members: Provider .Rolg Team/Code Leader ME BE RN Code Events: Tvne Value Date Compress ions 08/10/201906:35 CPR Lifepak 08/10/2019 06:39 EKG/Monitor No shock advised Compressions 08110/201906:40 CPR Oxygen 15 L 08/10/2019 06:47 IV Access Peripheral IV 08/10/2019 06:48 18 g Left AC Airway Endotracheal Tube 08/10/2019 07:08 ET Tube 7.5 24CM to L Up line Placed by Paramedics Medications Epinephrine lmg 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 08/10/201907:13 CPR Compressions 08/10/2019 07:14 Medications Sodium Bicarbonate 1 mEa/kg IV 08/10/201907:14 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 o the floor of his cell unresponsive with CPR in progress by correctional officers, inmate was Cold, with circumferential B wising 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, 02 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 RN Bureau of Prisons NYM Page 1 of 2 GeneratedOa/10/201g 08:10 by 'M. EFTA00132698  Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Facility: NYM Sex: TE Date of Birth: 01/20/1953 RN Unit: Z04 Encounter Date: 08/10/2019 07:25 Provider: Sinai Exam: ASSESSMENT: Cardiac Arrest PLAN: New Consultation Requests: Translator Language Consultation/Procedure Target atft Scheduled Target Date Priority Emergent No Emergency Room 08/10/2019 08/10/2019 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. Page 2 of 2 RN Busoou of Prisons - NYM Generated 08/1012019 08:10 by EFTA00132699  Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 7631 Date of Birth: 0120/1953 Sex: M Race: WHITE FadlIty NYM Encounter Date: 07/30/2019 15:58 Provider: MD Unit ZO1 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: i 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 Al-IS 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 AuscuItatIon 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 MD Bureau of Prisons - NYM Pigs t oft Generated 07/3O12019 18:12 by EFTA00132700  Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Facility: NYM Date of Birth: 01/20/1953 Sex: Provider: MD Unit: 201 Encounter Date: 07/30/2019 15:58 Exam: Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor SystemStrength 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. Hyperlipidemla, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes. R7303 - Current Sloop apnea, G4730 - Current PLAN: Now Medication Orders: Order Date Proscriber Order aXE Medication 07/30/2019 15:58 SLIDING SCALE INsulin REG - Human Subcutaneously each morning x 7 day(s) Pill Line Only Indication: Preciabetes Discontinued Medication Orders: Order Date Prescriber Order RAE tlodlc Ion 07/30/2019 15:58 Inject regular insulin 122148-NYM Insulin Reg (10 ML) 100 UNITS/ML Inj subcutaneously) per sliding scale: twice daily line"' for 7 days Discontinue Type: When Pharmacy Processes Discontinue Reason: new order written Indication: Copay Required: No Cosign Required: No TelephoneNerbal Order: No Completed by MD on 07/30/2019 16:12 Pera2d 2 MD Bureau of Prisons - NYM Generatod 07/30/2019 16:12 by EFTA00132701  Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg II: 76318-054 Date of Birth: 01/20/1953 Sex: i m :SIE Facility: NYM Encounter Date: 07/30/2019 11: t 2 Provider: MD Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Ma= MD Chief Complaint: Other Problem Subjective: PATIENT S REFERRED BY THE WARDEN FOR EVALUATION. PATIEN RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO 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 DENI SIDED WEAKNESS. DIPLOPIA. FACIAL DROOP, DIFFICULTY SPFAKING OWING. HE REPORT IA OF ABOUT 5 TIMES,. HE DENIES DYSUHIA. HE REPORTS oNEY STONES. HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEW AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCF HE HASB EEN HERE:6 CE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE R ELKED HIS CPAP MACHINE AND IT WILL tit GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-MEI51 UES. STATES HE FEELS OTHERWIS E N Pain: Not Applicable Seen for clinic(s): Endocrine/Lipid, Orthopodic/Rheumatology, OBJECTIVE: Pulse: Time Rate Per Minute Location 94 MD 07/30/2019 13:02 88 Via Machine ouin MD 07/30/2019 09:40 87 Via Machine MD 07/30/2019 09:30 Respirations: Date Time Rate Per Minute Egivider 07/30/2019 09:30 NYM 12 MD Blood Pressure: Time Value Location Position Cuff Size Provider Date Left Arm Standing MD 07/30/2019 13:02 NYM 114/84 Right Arm Standing Robert MD 07/30/2019 09:40 NYM 125/60 Left Arm Sitting MD 07/30/2019 09:30 NYM 108/86 SaO2: Data Time Valuef%1 ejr Provider 09:30 NYM 98 Room Air MD 07/30/2019 Weight: 11011 Time Kg Waist Circunt Provider Page 1 of 3 Generated 07/30/2019 14:05 by MD Bureau of Prisons • NYM EFTA00132702  Reg #: 76318.054 Inmate Namct• EPSTEIN. JEFFREY EDWARD Race: WHITE Facility: NYM Sex: M Date of Birth: 01/20/1953 MD Unit: Z01 Provider: Encounter Date: 07/3012019 11:12 Date Time Lbs SI g Waist Circum &vat 88.1 MD 07/3042019 nq.:3o NYM 194.2 Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, No: Appears Distre ed, Dyspneic, Appears in Pain, Disheveled, Unke cutely III Nutrition No: Appears O Pulmo nary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR 1 and S2 No: MIR/G Musculoskeletal Tibia / ribule No: Edema Neurologic Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Str