EFTA00110337.pdf

BP-S358.060 SEP 05 MEDICAL TREATMENT REFUSAL CDFRM 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 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 5X re 5 following my tions. 7-24-2019 unse Date NYM-NEW YORK MCC EFTA00110337 BP-S358.C60 MEDICAL TREATMENT REFUSAL CDFRM 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)waslwere 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 andlor 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 Counseled by Date Patien Signature Date 1 11 gna ure o Wilii Mess Date - ( 0( NYM-NEWYORK MCC EFTA00110338  I I I. BP-5358.060 MEDICAL TREATMENT REFUSAL CDFRM 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 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 Dale Pa nes Sign r Date NYM--NEW YORK MCC EFTA00110339 BF-A0618 A&O DENTAL EXAMINATION JUN 16 (Initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Occlusion: Oral Hygiene: Good Fair , oar • AA 1 2 1 4 5 6 7 8 9 1011 1213 14 15 18 Fri CP:TN: Head 8 Neck / Soft Tissue: 3 3 3 3 O CC 32 31 30 2D 28 27 2825 24 23 22 21 20 19 • 18 17 21 Classification: mmomel;;' D: M: I CL F: Pain Scale: /10 Dental Prostheses at intake: ComnAl Ii7 aO r rI jt , riV )72.5 i Vet" es Type: Age: No r-ccess.cy-) ekt Sen) -e- OL-7e-e- 0--Niell or Citr-s.SAJA c O.105re-M41 Contrition: Intra-oral Photos Taken: Radiographs Taken: (Document findings on A8O encounter) Yes Yes 0 9 • Instructed how to obtain urgent and non-urgent dental care: Yes: 1 No: Treatment Priorities: None: Non-urgent Urgent Referred to Sick Cali: non-urgent Radiographs authorized: Prophylatis authorize& Yes i No PM: (Approval valid 18 months from examination date) BWs: Perron= frit Name: i Den' km Skin .. f- Number. i -O—e_Fici--e_ty S institution: / Date: Signature Block/Stamp: --7(, 3 lc= Us-Li MCC NEW YORK 7- 26 -/ 9. DOS. let uentatofficer MCC New York PDF Presaibed by P6400 Replaces BP-A0618 of JUN 10 EFTA00110340 BP-A0618 A&O DENTAL EXAMINATION JUN 18 (initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Occlusion: Oral Hygiene: Good Fair Poor CPFIN: 3 2- 3 3 2 — Head & Neck / Soft Tissue: I 1 2 3 4 5 0 7 8 0 1011 1213 14 15 16 rm- 0 32 31 30 2D 28 27 26 25 24 23 22 21 20 10 18 17 Classification: D rt I CL_ F: Pain Scale: /10. Dental Prostheses at Intake: Comzrt _to z it t bett v ri i ..g),:iiilitca Yes No Type: R Ce SS / OO DICX Sen.)-e-a Ae: Condition: Lot-Act 0--4,4 pc Ce-O-1,O-ini ojoScAle4 Intra-oral Photos Taken: . Radiographs Taken: (Document findings on A&O encounter) Yes yes 0 O • Instructed how to obtain urgent and non-urgent dental care: Yes: I No: Treatrnent Priorities: None: Non-urgent Urgent Referred to Sick Can: non-urgent Radiographs authorized: - Prophybcds 811 k Yes i No PM: (Approval vaad 18 months from examination date) BWs: Panorer Patient Name: Dent; • ,,-- sir $4Qn i -3 -e_cThy E ft , r Number. Institution: / Date: Signature Block/Stamp: 76 3 iSC OS-LI MCC NEW YORK 7— 24, -1 9. DDS. Chief Dental Officer MCC New York PDF Prescribed by P6400 Replaces BP-A0618 of vUN 10 EFTA00110341  OP-5358.060 MEDICAL TREATMENT REFUSAL COFRM 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 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 Pa nt's Sign Dale NYM-NEW YORK MCC EFTA00110342  Federal U.S. Medi Bureau of Prisons **' Sensitive But Unclassified "' Name EPSTEIN, JEFFREY Facility MCC New York Collected 07/09/2019 13:34 Reg # 76318-054 Order Unit E06-547U Received 07/10/2019 10:44 DOB 01/20/1953 Provider MD Reported 07/10/2019 14:46 Sex M LIS ID 188191004 I HIV HIV 1/2 Negative Negative Screening test - See confirmatory testing for Reactive results FLAG LEGEND L=Low LI=Low Critical H=High H!=High Critical A=Abnormal A! =Abnormal Critical Page 3 of 3 EFTA00110343  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: 07/10/2019 16:58 Provider: Lab Result Receive Facility: NYM Cosigned by MD on 07/14/201918:12. Bureau of Prisons - NYM EFTA00110344 BP-5358.C60 MEDICAL TREATMENT REFUSAL CDFRM 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 treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. t i 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. D 7-24-2019 t Counseled by Date Pa nts Sign Date NYM--NEW YORK MCC EFTA00110345 BP-A0618 A&O DENTAL EXAMINATION JUN 16 (Initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Occlusion: • Oral Hygiene: Good Far / Oct CPITfit. 3 3 Head & Neck/Soft Tissue: 3 2- 3 2 3 4 5 8 7 B 9 1011 1213 14 15 16 2 CC 32 31 30 29 28 27 28 25 24 23 22 21 20 19 • 18 17 Classification: D: '.4!1fl!Ir't CLer tit M: F: Pain Scan: /10 It Dental Prostheses at Intako: Cowl ek = et in 1 vca Yes No Type: RCe SS / De) CIPSen.)-e- • Age: LoLjta - C,..-s...ko..4 or Condlion: Cal-Oa:MS 0.105refil 4 Intra-oral Photos Taken: Radiographs Taken: (Document findings on MO encounter) Yes Yes • 0 No Instructed how to obtain urgent and non-urgent dental care: Yes: i No: Treatment Priorities: None: Non-urgent Urgent Referred to Sick Call: non-urgent Ftadlographs authorized; Prophylaxis authorized: Yes I No PM: (Approval valid 18 months from examination date) BWs: Panorex-. Pa'ant Nam Denhs 4.4 .. k a n i N&inber --).6 1P-9._ v S 1) 1)-5 Institution: / Date: Signature Block/Stamp: 76 3 I Sr- USN MCC NEW YORK -7- zOi --1 9. IIIIMDDS. let en a icer MCC New York PDF Presaibed by P64C0 RepNces BP-A0618 of JUN 10 EFTA00110346 SP-S358.060 MEDICAL TREATMENT REFUSAL COFRM 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 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. D 7-24-2019 Counseled by Date NYM-NEW YORK MCC EFTA00110347 BP-S358.060 MEDICAL TREATMENT REFUSAL CDFRM 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 PIVIHX , 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 tho 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 Counseled by Date Patient Signature Date Signature of Witness NYM-NEW YORK MCC Date EFTA00110348 E3P-A0618 A&O DENTAL EXAMINATION JUN 16 (Initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Occlusion: Fair Poor • NM Oral Hygiene: Good CPITN: 3 z 3 Head & Neck! Soft Tissue: 2- 2 X- 1 2 3 4 5 8 7 8 9 1011 1213 14 15 16 WI L9 32 31 30 20 28 27 2625 2423 22 21 20 10 18 17 Classification: D: M: CL? F: Pain Sonic: /1G Dental Prostheses at Intake: Comin 42 120.- Yes No tel 17.25 I IAa Type: it (12 SSi on Di,Seru-e. • Age: Za...,ter 0....N. skol or Congini 0.1054/4 4 Condition: Intra-cral Photos Taken: Radiographs Taken: (Document findings on A&O encounter) Yes Yes 0 9 • Instructed how to obtain urgent and non-urgent dental care: Yes: I No: Treatment Priorities: None: Non-urgent Urgent Referred to Sick Cal. non-urgent Radiographs authorized: • Prophylaxis authorized: Yes I No PM: (Approval vaFrl 18 months from examination date) BWs: Panormc Pent Name: i 4 Denblil t 4 sti n , --)c-C-Vizy E Number. / bps Signature Block/Stamp: Institution: / Date: --n, 3 IQ: ()Sy MCC NEW YORK 7-2-6 --1 9 . DDS. Chief Dental Officer MCC New York PDF Prescribed by P6403 Replaces BP-A0618 of JUN10 EFTA00110349  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: 08/1012019 07:25 Provider: RN Unit: Z04 Emergency Code - Resuscitation Event encounter performed at Special Housing Unit. SUBJECTIVE: Emergency Note Provider: RN Team Members: Provider Ha& RN Team/Code Leader Code Events: Tvoe Value Date CPR Compressions 08/10/2019 06:35 EKG/Monitor Lifepak 08/10/201906:39 No shock advised CPR Compressions 08/10/2019 06:40 Oxygen 15L 08/10/201906:47 IV Access Peripheral IV 08/10/2019 06:48 18g Left AC Airway Endotracheal Tube 08/10/2019 07:08 ET Tube 7.5 24CM to L Lip line Placed by Paramedics Medications Epinephrine 1mg IV 08/10/201907:10 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 08110/2019 06:10 by RN Bureau of Prisons - NYM Page 1 of 2 EFTA00110350 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 Data Scheduled Target Dais Priority Translator Languaae 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 NY10/2019 08:10 by RN Bureau or Prisons • NYM Page 2 of 2 EFTA00110351  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 Ginersted 07/30/2019 16:12 by MD Bureau of Prisons • NYM Page 1 of 2 EFTA00110352 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 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: Medication Order Date Prescriber Order INsulin REG - Human 07/30/2019 15:58 SLIDING SCALE Subcutaneously each morning x 7 day(s) Pill Line Only Indication: Prediabetes Discontinued Medication Orders: Bat Medication Order Date Prescriber Order 122148-NYM Insulin Reg (10 ML) 100 UNITS/ML Inj 07/30/2019 15:58 Inject regular insulin subcutaneously per sliding scale: twice daily "pill 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 Generated 07/30/2019 16:12 by MD Bureau of Prisons • NYM Page 2 of 2 EFTA00110353  Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg /I: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: MD Unit: 201 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: 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 S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STAT BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. HE DEN SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING J. OWING. HE REPORT • Tfiki!J7 IA OF ABOUT 5 TIMES.. HE DENIES DYSURIA. HE REPORTS H t b NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEP AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN CE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE R E HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-ME I STATES HE FEELS OTHERWISE Pain: Not Applicable Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology, OBJECTIVE: Pulse: Date Time Rate Per Minute Location 07/30/2019 13:02 94 MD 07/30/2019 09:40 88 Via Machine MD 07/30/2019 09:30 87 Via Machine MD Respirations: Date Time Rate Per Minute provides 07/30/2019 09:30 NYM 12 MD Blood Pressure: Date Time Value Location position Cuff Size provider 07/30/2019 13:02 NYM 114/84 Left Arm Standing MD 07/30/2019 09:40 NYM 125/60 Right Arm Standing MD 07/30/2019 09:30 NYM 108/86 Left Arm Silting MD SaO2: Date Time Value(%) Air Provider 07/30/2019 09:30 NYM 98 Room Air MD Weight: Date Time Lbs Kg Waist Circum. Provider Generated 07/302019 14:05 by MD Bureau of Prisons NYM Page 1 of 3 EFTA00110354 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: MD Unit: Z01 DAR Time Lb.S. Kg Waist Circurn, Pioxider 07/30/2019 09:30 NYM 194.2 88.1 MD Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distre ed, Dyspneic. Appears in Pain. Writhing in Pain. Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unke cutely III Nutrition No: Appears Ob Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR 1 and S2 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, R7303 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: Medication Order Date Prescriber Order Generated 07/30/2019 14:05 by MD Bureau of Prisons • NYM Page 2 of 3 EFTA00110355 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: MD Unit: Z01 New Medication Orders: Rx# Medication Order lade Prescriber Order Magnesium Hydroxide Susp conc 800 07/30/2019 11:12 10 CC Orally - Two Times a MG/5ML Day PRN x 90 day(s) Indication: Constipation, unspecified INsulin REG - Human 07/30/2019 11:12 SLIDING SCALE Subcutaneously - Two Times a Day x 7 day(s) Pill Line Only Indication: Prediabetes Renew Medication Orders: &,t1 Medication Order Date Prescriber Order 121836-NYM methylPR ne 4 MG Tab ( 21 count 07/30/2019 11:12 Take the tablet by mouth as Pack) directed x 6 day(s) Indication: a and neuritis, unspecified New Laboratory Requests: Details EteStiallca Due Date Priority Lab Tests - Short List-General-CBC w/diff ne Time 08/01/2019 00:00 Routine Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short Lisl-General-Comprehensiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic New Radiology Request Orders: Details Frequency Due Date Priority General Radiology-Spine / Cervical- One Time 08/29/2019 • Routine General Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUIMR ESS1PAR 2-3 MINUTES 3 DAYS AGO. PLEASE PERFORM C SPINE SERIES Disposition: aic Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format Handout/Topic Outcome 07/30/2019 Counseling Access to Care Verbalizes Understanding 07/30/2019 Counseling Plan of Care Verbalizes