2019-05665

2019-05665 Item 9, 13, 17 (partial), 18 (partial) EFTA00073831 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 08/10/2019 07:25 Provider Reg #: 76318-054 M Race: WHITE Facility: NYM RN Unit: Z04 Emergency Code Resuscitation Event encounter performed at Special Housing Unit. SUBJECTIVE: Emergency Note Provider: RN Team Members: Provider Bole RN Team/Code Leader Code Events: Type 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 Page 001 of 148 Airway Endotracheal Tube 08/10/2019 07:08 Withheld pursuant to exemption ET Tube 7.5 24CM to L Lip line Placed by Paramedics Medications Epinephrine 1mg IV (b)(6) (b)(7)(A); (b)(7)(C) 08/10/2019 07:10 Epinephrine 3 doses and Sodium bicarb 2 doses administered by paramedics CPR Compressions of the Freedom of Information and Privacy Act, cro/10/2019 07:11 Medications Sodium Bicarbonate 1 mEaikg 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 mEaikg 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 10 2019 08.10 by RN Bureau of Prisons - NYM Page 1 of 2 EFTA00073832 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: 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 Cosign documentation will be displayed on the following page. Page 002 of 148 Withheld pursuant to exemption (b)(6) : (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Generated 08/1012019 08:10 by RN Bureau of Prisons NYM Page 2 of 2 EFTA00073833 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 08/10/2019 07:25 Provider: RN Facility: NYM Cosigned by on 08/12/2019 08:09. Page 003 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073834 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 07/30/2019 15:58 Provider M Race: WHITE 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 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 ISSUE rage uu4 of 148 STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Withheld pursuant to exemption Seen for clinic(s): Pulmonary/Respiratory. Orthopedic,Rheumatology, Endocrine/Lipid (b)(6), (b)(7)(C) OBJECTIVE: of the Freedom of Information and Privacy Act 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 SI and S2 No: MITG Musculoskeletal Tibia / Fibula No: Edema Neurologic Generated 07 302019 16.12 by Bureau of Prisons - NYM Page 1 of 2 EFTA00073835 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Encounter Date: 07/30/2019 15:58 Sex: Provider M Race: WHITE Reg #: 76318-054 Facility: NYM Unit: 701 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: Page 005 of 148 New Medication Orders: Rxtl Medication INsulin REG - Human Withheld pursuant to exemption Order Date (b)(8); (b)(dXM10;/0)(g)11%)58 of the Freedom of Information and Privacy Act Indication: Prediabetes Discontinued Medication Orders: Rx# Medication Order Date 122148-NYM Insulin Reg (10 ML) 100 UNITSML lnj 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 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 line"' for 7 days Generated 0730:2019 16:12 by Bureau of Prisons - NYM Page 2 of 2 EFTA00073836 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/30/2019 11:12 Provider: 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 PIN Pain: Not Applicable Withheld 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 Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology' (b)(6) (b)( OBJECTIVE: Pulse: Dale 07/30/2019 07/30/2019 07/30/2019 Respirations: pate Time 07/30/2019 09:30 NYM €W8 of 148 o exemption of the Freedom of Information lime Rate Per Minute 13:02 94 09:40 88 09:30 87 Location Via Machine Via Machine Rate Per Minute Provider Blood Pressure: Date limes Value Location 07/30/2019 13:02 NYM 114/84 Left Arm 07/30/2019 09:40 NYM 125/60 Right Arm 07/30/2019 09:30 NYM 108/86 Left Arm SaO2: Dale lime Value(%) Air 07/30/2019 09:30 NYM 98 Room Air Weight: Date Time Lbs 12 Respiratory XC) Position Standing Standing Sitting Provider eaudouin, Robert MD &Quin. Robert MD Robert MD Cuff Size Provider Provider Kg Waist Circum. Provider Generated 07/30/2019 14:05 by Bureau of Prisons - NYM Page 1 of 3 EFTA00073837 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 07/30/2019 11:12 Provider: Reg #: 76318-054 M Race: WHITE Facility: NYM Unit: Z01 Date Time Lba Kg Waist Circum, Provider 07/30/2019 09:30 NYM 194.2 88.1 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 1 and S2 No: Mil(G Musculoskeletal Tibia / Fibula No: Edema Neurologic Cranial Nerves (CN) of the Freedom of Information Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Withheld e 007 of 148 exemption (b)(8). (b)(7) ( )(C) 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 Prediabeles, R7303 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: R x# Medication Order Date Prescriber Order Generated 07/30.2019 14.05 by Bureau of Prisons - NYM Page 2 of 3 EFTA00073838 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 07/30/2019 11:12 Provider Reg #: 76318-054 M Race: WHITE Facility: NYM Unit: Z01 New Medication Orders: Rx# Medication Magnesium Hydroxide Susp conc 800 MG15ML Indication: Constipation. unspecified INsulin REG - Human Indication: Prediabetes Renew Medication Orders: Rxff Medication Order Date Prescriber Order 121836-NYM methylP 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 Frequency Due Date Priority Lab Tests - Short List-General-CBC w diff ane Time 08/01/2019 00:00 Routine 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: Order Date 07/30/2019 11:12 07/30/2019 11:12 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 008 of 148 Withheld e emption Details Frequency Due Date General Radiology-Spine / Cervical- One Ti(ix)(6); (b)( )(C) 08/29/2019 General Specific reason(s) for request (ttfififtSiffigraei6 InfRnalje 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI PLEASE PERFORM C SPINE SERIES Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date initiated Format 07/30/2019 Counseling Handout/Topic Access to Care 07/30/2019 Counseling Plan of Care Copay Required:No Cosign Required: No Telephone, Verbal Order: No Completed by on 07/30/2019 14:05 Priority Routine 2-3 MINUTES 3 DAYS AGO. Pipit l Outcome Beaudo Robert Verbalizes Understanding Verbalizes Understanding Generated 07 30'2019 14:05 by Bureau of Prisons - NYM Page 3 of 3 EFTA00073839 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT REFERRED BY THE WARDEN FOR EVALUATION. PATIE RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALS 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 DEN HI SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OWING. HE REPORT IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. HE REPORTS '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 EBED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-ME STATES HE FEELS OTHERWISE PIN Pain: Not Applicable Withhelddi o exemption Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology, Respiratory (b)(6) (b)( )(C) 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 of the Freedom of Information Respirations: Date lime Rate Per Minute Provider 07/30/2019 09:30 NYM 12 Blood Pressure: Data 07/30/2019 07/30/2019 07/30/2019 SaO2: Time Value Location Position 13:02 NYM 114/84 Left Arm Standing 09:40 NYM 125/60 Right Arm Standing 09:30 NYM 108/86 Left Arm Sitting Provider eaudouin, Robed MD e ouin. Robed MD Robert MD Cuff Size Provider Date Time Value(%) Alt Provider 07/30/2019 09:30 NYM 98 Room Air Weight: Pale Time Lin Kg Waist Circum. Provider Generated 07/3012019 14:05 by Bureau of Prisons - NYM Page 1 of 3 EFTA00073840 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 07/30/2019 11:12 Provider: M Race: WHITE Reg #: 76318-054 Facility: NYM Unit: Z01 Dale Time 07/30/2019 09:30 NYM 194.2 88.1 LIM 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•IG Musculoskeletal Tibia / Fibula No: Edema Neurologic Cranial Nerves (CN) of the Freedom of Information Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: 1 and S2 e 010 of 148 le exemption (b)(6): (b)( ) • (• )(C) 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: Exit Medication Order Date Prescriber Order Generated 07/3012019 14:05 by Bureau of Prisons - NYM Page 2 of 3 EFTA00073841 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: Unit: Z01 New Medication Orders: BLit( Medication Order Date 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: &ft Medication Order Date Prescriber Order 121836-NYM methylP 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 Frequency Lab Tests - Short List-General-CBC w diff ane 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 ft 8ffirfffeftliekilfliRMISP 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI PLEASE PERFORM C SPINE SERIES Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format Handout/Topic Prov Outcome 07/30/2019 Counseling Access to Care Beaudo Robert Verbalizes Understanding 07/30/2019 Counseling Plan of Care Verbalizes Understanding Frequency One Ti0b)(6); (b e 011 of 148 Due Date 08/01/2019 00:00 Routine Priority e emption Due Date )(C) 08/29/2019 Priority Routine 2-3 MINUTES 3 DAYS AGO. Copay Required:No Cosign Required: No TelephoneNerbal Order: No Completed by on 07/30/2019 14:05 Generated 07130/2019 14:05 by Bureau of Prisons - NYM Page 3 of 3 EFTA00073842 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/30/2019 15:58 Facility: NYM Amendment made to this note by on 07/30/2019 16:12. Page 012 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons - NYM EFTA00073843 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN. JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 07/28/2019 20:25 Provider Reg #: 76318-054 M Race: WHITE Facility: NYM 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, hand still has pins and needles sometimes" No change in appearance from previous exam. Pain: No OBJECTIVE: Pulse: Date Time 07/28/2019 20:28 Respirations: Date 07/28/2019 Blood Pressure: Date Time 07/28/2019 20:28 NYM SaO2: Date Time yatue(%) Air 07/28/2019 20:28 NYM 98 Rate Per Minute Location Rhythm Provider Time 20:28 NYM Value 157/91 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 0712812019 20:30 by 81 Rate Per Minute Provider 14 Withheld pursuant to exemption Location (b)WPO:jR9)(A): (b)Filk-PiZe of the Freedom of Information and Privacy Act Provider Provider RN RN RN RN Bureau of Prisons - NYM Page 1 of 2 EFTA00073844 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 07/28/2019 20:25 Provider Reg #: 76318-054 M Race: WHITE Facility: NYM RN Unit: H01 Follow-up in 12-24 Hours Patient Education Topics: ttate_lnitiated Formal Handout/Topic 07/28/2019 Counseling Plan of Care Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Completed by RN on 07/28/2019 20:30 Requested to be cosigned by Cosign documentation will be displayed on the following page. Page 014 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Provider Outcome Verbalizes Understanding Generated 07/28/2019 20:30 by RN Bureau of Prisons - NYM Page 2 of 2 EFTA00073845 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/28/2019 20:25 Provider: RN Facility: NYM Cosigned by on 07/28/2019 20:50. Page 015 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073846 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] 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: Dale Time 07/28/2019 06:57 Rate Per Minute location Rhythm Provider 82 Respirations: DAM lime Rate Per Minute Pr vider 07/28/2019 06:57 NYM 14 Blood Pressure: Dale Time Value LocationWithhe0cPtlif8iint to extaidni(gize 07/28/2019 06:57 NYM 138/80 (b)(6) : (b)(7)(A): (b)(7)(C) SaO2: of the Freedom of Information and Privacy Act DAM Time ValuerY41 Alt Provider 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 Head General Yes: Symmetry of Motor Function, AtraumaticlNormocephalic No: Facial Asymmetry, Battle's Sign, Raccoon Eyes, Deformity Eyes General Yes: , Extraocular Movements Intact Face General Yes: Symmetric Generated 07128;2019 07:22 by■ RN Provider RN RN RN Bureau of Prisons - NYM Page 1 of 3 EFTA00073847 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 07/28/2019 06:51 Provider Reg #: 76318-054 M Race: WHITE Facility: NYM 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 Symmetric, No: Swelling I, Inflammation' Humerus Yes: Within Normal Limits, Elbow Yes: Normal Exam I, Full Range of Motion', Nikkfie0tnicibrlifeilpation I Radius / Ulna Withhdd pursuant to exemption Yes: Normal Exam Full Range of Motion I Wrist/Hand/Fingers (b)(6); (b)(7)(A) ; (b)(7)(C) Yes: Full Range of Motion RoNtitio*HefRAAtigoog•Awitleiviic9 Act No: Inflammation I. Ecchymosis Erythema'. Tenderness Laceration(s) I, Abrasion(s) I, Contusion(s) I ROS 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. ViS 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 an ain numbness 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 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 Page 2 of 3 EFTA00073848 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 07/28/2019 06:51 Provider: Reg #: 76318-054 M Race: WHITE Facility: NYM RN Unit: H01 Date Initiated Format Randoutagpic Provider Outcome Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Completed by RN on 07/28/2019 07:22 Requested to be cosigned by Cosign documentation will be displayed on the following page. Page 018 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM Page 3 of 3 EFTA00073849 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/28/2019 06:51 Provider: RN Facility: NYM Cosigned by on 07/28/2019 20:51. Page 019 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073850 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Note Date: 07/26/2019 08:57 Provider: Reg #: 76318-054 Parr WHITE Facility: NYM Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. New Medication Orders: That Medication Order Date 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 Telephone Verbal Order: No Completed by Cosign Required: No on 07/26/2019 08:58 Page 020 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A) (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07126,2019 08:58 by Bureau of Prisons NYM Page I of I EFTA00073851 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth [DOB REDACTED] Sex: Rate WHITE Facility: NYM Note Date: 07/24/2019 16:10 Provider: Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: 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 1 e 021 of 148 i.co Withheld exemption (b)(6) ; (b) ) , ( )(C) of the Freedom of Information Generated 07/24/2019 16:12 by Bureau of Prisons - NYM Page 1 of 1 EFTA00073852 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth [DOB REDACTED] Sex: Rare-WHITE Facility: NYM Note Date: 07/24/2019 16:10 Provider: Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: 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 1 il e 022 of 148 p Withheld o exemption (b)(6) ; (b) , ( )(C) of the Freedom of Information Generated 07/24/2019 16:12 by Bureau of Prisons - NYM Page 1 of 1 EFTA00073853 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/26/2019 08:57 Facility: NYM Amendment made to this note by on 07/26/2019 08:58. Page 023 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons - NYM EFTA00073854 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth [DOB REDACTED] Sex: m Rare•WHITE Facility: NYM Note Date: 07/24/2019 15:10 Provider: Unit: H01 Admin Note - General Administrative Note encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: PATIENT WAS OFFERED TO HAVE AN OPTOMETRIST EVALUATION. HE REFUSED. REFUSAL FORM SIGNED. Copay Required:No TelephoneNerbal Order: No Completed by Cosign Required: No on 07/24/2019 15:17 Page 024 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/24/2919 15:17 by Bureau of Prisons - NYM Page 1 of 1 EFTA00073855 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Facility: NYM Encounter Date: 07/24/2019 13:08 Provider: Unit: H01 Mid Level Provider Follow up Visit encounter performed at Receiving & Discharge. SUBJECTIVE: COMPLAINT 1 Provider: 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 Tittle Fa_hienteit GetSiu_s LOCatiOn Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/24/2019 13:12 83 Via Machine Regular Page 025 of 148 Blood Pressure: Date Time Value LocationWithheislamnt to extriiiiivze Provider 07/24/2019 13:12 NYM 132/89 Right Arm (b) jtirm(7)(A): (b)Mayegular SaO2: of the Freedom of Information and Privacy Act Date Time Value(%) Air Provider 07/24/2019 13:12 NYM 96 Room Air 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 male. But does not want to talk about it. ASSESSMENT: Injury, unspecified. T1490 - Current PLAN: Disposition: Generated 07 24 2019 13.24 by Bureau of Prisons - NYM Page 1 of 2 EFTA00073856 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/24/2019 13:08 Provider: Reg #: 76318-054 Facility: NYM Unit: H01 Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format 07/24/2019 Counseling 07/24/2019 Counseling Copay Required:No Telephone/Verbal Order: No Completed by on 07/2412019 13:24 Requested to be cosigned by Cosign documentation will be displayed on the following page. Handout/Topic Access to Care Preventive Health Cosign Required: Yes Page 026 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Provider Outcome Verbalizes Understanding Verbalizes Understanding Generated 07)242019 1324 by Bureau of Prisons • NYM Page 2 of 2 EFTA00073857 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/24/2019 13:08 Provider: Facility: NYM Cosigned with New Encounter Note by on 07/24/2019 16:10. Page 027 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073858 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: Unit: H01 Injury Assessment Non-work related encounter performed at Health Services. SUBJECTIVE: INJURY 1 Provider: 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 Page 028 of 148 OBJECTIVE: Withheld pursuant to exemption Temperature: u(b)aar tigr)i(A) ; (b)(71(C) . Date Time Fahrenheit Cglsi_s Provider 07 23 2019 06:30 NYM 91.Se FreeSOPA o(ynibrmation and PthsvOlip1Y. MLP Pulse: Dale Time Rate Per Minute Location 07723/2019 06:30 92 Via Machine Regular Respirations: Date Time Rate Per Minute Provider 07/23/2019 06:30 NYM 16 Blood Pressure: Date Time Value Location Position 07/23/2019 06:30 NYM 140/85 Right Arm Sitting Adult-regular SaO2: Date Time Value(%) Air Provider 07/23/2019 06:30 NYM 96 Room Air Rhy►hm Provider Cuff Size Provider 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 0712312019 09.05 by Bureau of Prisons NYM Page 1 of 2 EFTA00073859 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M R : WHITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: 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: Page 029 of 148 Injury, unspecified, T1490 - Current -'iO self inflicted injuries. Withheld pursuant to exemption PLAN: (b)(6). (b)(7)(A) (b)(7)(C) Disposition: Follow-up at Sick Call as Needed Placed on Suicide Watch Follow-up in 2-4 Hours of the Freedom of Information and Privacy Act Other: For follow up with psychology service. Patient Education Topics: Date Initiated Format Handout/Topic Provider 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 on 07`23 2019 09:05 Requested to be cosigned by Cosign documentation will be displayed on the following page. Generated 07/23/2019 09:05 by Bureau of Prisons - NYM Page 2 of 2 EFTA00073860 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/23/2019 06:20 Provider: Facility: NYM Cosigned by on 07/23/2019 15:44. Page 030 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073861 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 07/14/2019 17:36 Provider Reg #: 76318-054 M Race: WHITE Facility: NYM Unit: Z05 Chronic Care 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDOLIPID 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 Page 031 of 148 Location: Back-Middle Withheld pursuant to exemption Quality of Pain: Shooting Pain Scale: 5 (b)(6); (b)(7)(A); (b)(7)(C) Intervention: MEDRerl-take86‘616f Information and Privacy Act 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 07/1422019 18:11 by Bureau of Prisons - NYM Page 1 of 3 EFTA00073862 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/14/2019 17:36 Provider: Reg #: 76318-054 Facility: NYM 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: Milt 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: Page 032 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A) , (b)(7)(C) of the Freedom of Information and Privacy Act 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: RAE 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 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 Bureau of Prisons - NYM Page 2 of 3 EFTA00073863 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 07/14/2019 17:36 Provider Reg #: 76318-054 M Race: WHITE Facility: NYM Unit: Z05 FASTING. Lab Tests-H-Hep B surface Ab Lab Tests-H-Hep B surface Ag Lab Tests-H-Hep C Ab Lab Tests-H-Hepatic Profile Schedule: One Time 08/08/2019 00:00 Routine 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: Qate_initiated Format Handout/Topic 07/14/2019 Counseling Diagnosis Copay Required: No Cosign Required: N9age 033 of 148 Telephone Verbal Order: No Withheld pursuant to exemption Completed by 011 07 14.'2019 18:11 (b)(6); (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Provider Outcome Verbalizes Understanding Generated 07/14/2019 18:11 by Bureau of Prisons - NYM Page 3 of 3 EFTA00073864 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 07/12/2019 13:10 Provider M Race: WHITE Reg #: 76318-054 Facility: NYM Unit: Z05 Chronic Care 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDOiLIPID 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 SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREM S. SURGICAL HX: NONE MENTAL HEALTH HX: Pain: Yes Pain Assessment Date: Location: Quality of Pain: Pain Scale: Intervention: MEDRatlig:ISielaitWlef Information Trauma Date'Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: 07/1212019 13:25 C Se 034 of 148 Back-Middle Withheld bt4o exemption Shooting 5 (b)(6): (b)(7) , (' - )(C) 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 07ft2/2019 14:20 by Bureau of Prisons - NYM Page 1 of 3 EFTA00073865 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/12/2019 13:10 Provider: Reg #: 76318-054 Facility: NYM Unit: Z05 Exam: Eyes General Yes: , Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal S1 and S2 No: Mit 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: e 035 of 148 le o exemption (b)(6) : (b)( ) )(C) of the Freedom of Information 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: Medication Order Date Magnesium Hydroxide Susp 07/12/2019 13:10 Indication: Constipation, unspecified MethylPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 Pack 21 tab) Indication: Neuralgia and neuritis, unspecified Disposition: Prescriber Order 30 CC Orally - Two Times a Day PRN x 2 day(s) AS DIRECTED Orally - daily x 6 day(s) Generated 07/12/2019 14:20 by Bureau of Prisons - NYM Page 2 of 3 EFTA00073866 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 07/12/2019 13:10 Provider M Race: WHITE Reg #: 76318-054 Facility: NYM 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 4 e 036 of 148 ullo Withheld exemption (b)(6) ; (b) ) , ( )(C) of the Freedom of Information Provider Outcome Verbalizes Understanding Generated 07:12 2019 1420 by Bureau of Prisons - NYM Page 3 of 3 EFTA00073867 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 07/12/2019 13:10 Provider M Race: WHITE Reg #: 76318-054 Facility: NYM Unit: Z05 Chronic Care 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDO/LIPID Subjective: 66 YR 0 HYPER 800 . MED HX OF MACHINE. STATES TH L4 - L5 SEVERE LOWER EXTREM S. SURGICAL HX: NONE MENTAL HEALTH HX: Pain: Yes Pain Assessment Date: Location: Quality of Pain: Pain Scale: Intervention: Trauma Date Year: Injury: Mechanism: Onset: Duration: Exacerbating Factors: Relieving Factors: Reason Not Done: Comments: HITE MALE WITH HX OF CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE EIR GI SIDE EFFECTS. UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. Y HAS SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE 07/12/2019 13:25 Back-Middle Shooting 5 Withheld e 037 of 148 o exemption (b)(6): (b)( )(C) MEDRQ.tfAClb€e86Fil6f Information 5+ Years 5+ Years NO EXERCISE MEDROL DOSE PACK 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 Bureau of Prisons - NYM Page 1 of 3 EFTA00073868 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/12/2019 13:10 Provider: Reg #: 76318-054 Facility: NYM Unit: Z05 Exam: Eyes General Yes: , Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal S1 and S2 No: Milt 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: e 038 of 148 exemption (b)(6) ; (b)(7) ( )(C) of the Freedom of Information 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: 8/iff Medication Order Date Magnesium Hydroxide Susp 07/12/2019 13:10 Indication: Constipation, unspecified MethylPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 Pack 21 tab) Indication: Neuralgia and neuritis, unspecified Disposition: Prescriber Order 30 CC Orally - Two Times a Day PRN x 2 day(s) AS DIRECTED Orally - daily x 6 day(s) Generated 07/12/2019 14:20 by Bureau of Prisons - NYM Page 2 of 3 EFTA00073869 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: 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 07/12/2019 Counseling Copay Required:No Telephone/Verbal Order: Completed by Beaudouin, Handout/Topic Provider Outcome Diagnosis Verbalizes Understanding Cosign Required: No 07/12/2019 14:20 4 039 of 148 Withheld L e o exemption e (b)(6) , (b)( ) )(C) of the Freedom of Information Generated 07:12,2019 14:20 by Bureau of Prisons - NYM Page 3 of 3 EFTA00073870 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/14/2019 17:36 Facility: NYM Amendment made to this note by on 07/14/2019 18:11. Page 040 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons - NYM EFTA00073871 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: Date of Birth: Note Date: EPSTEIN, JEFFREY EDWARD 01/20/1953 Sex: Rana. WH ITF 07/12/2019 09:06 Provider: Reg #: Facility: Unit: 76318.054 NYM Z05 Admin Note - Orders encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: PATIENT REQUESTED TO HAVE A COLACE RX , INSTEAD OF TEH BISACODYL FOR CONSTIPATION. New Medication Orders: fixE Medication Order Date Docusate Sodium Capsule 07/12/2019 09:06 Indication: Constipation, unspecified Discontinued Medication Orders: Bx# Medication Order Date 121757-NYM Bisaoodyl E.C. 5 MG TAB 07/12./2019 09:06 Discontinue Type: When PharmacThicaises Di 148 Discontinue Reason:discoggilhheld pursuant to exemption Indication: Copay Required:No TelephoneNerbal Order: No Completed by (b)(6) : (b)(7)(A), (b)(7)(C) Cosign Required: No of the Freedom of Information and Privacy Act 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 07/122019 09:10 by Bureau of Prisons NYM Page 1 of 1 EFTA00073872 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: Date of Birth: Note Date: EPSTEIN, JEFFREY EDWARD 01;201953 Sex: 07/07/2019 00:17 Provider: Reg IS: 76318-054 Rant, WHITE Facility: NYM Unit: E06 Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MED CL:1 NO CCC APPT. Discontinued Laboratory Requests: Details Frequency Due Date Priority Lab Tests-H-Hemoglobin AIC One Time 08/05/2019 00:00 Routine Lab Tests-C-CBC w/diff Lab Tests-L-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: BeauoCNC, Ckg*ti reflb New Laboratory Requests: Withheld pursuant to exemption Details Frequency Due Date Priority Chronic Care Clinics-Diabetic-CBC w/diff (KM; Tlip(f)(A) (b)(7)(C) 07/25/2019 00:00 Routine Chronic Care Clinics-Diabetic-Lipid Profile Chronic Care Clinics-Diabetic-HemObOgiffrAggpm of Information and Privacy Act Lab Tests-H-HIV 1/2 Lab Tests-I-RPR Chronic Care Clinics-Diabetic-Comprehensive Metabolic Profile (CMP) New Radiology Request Orders: Deals 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 on 07/07/2019 00:30 Generated 07/07/2019 00:30 by Bureau of Prisons NYM Page I of I EFTA00073873 Bureau of Prisons Health Services Health Screen Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] 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 Carcinomatymphoma: Denied Allergies: Denied PPD Administration: Date!lime: 07 06 2019 21:39 Provider: PA-C Location: Right Forearm Page 043 of 148 Drug Mfg: Sanofi Pasteur Withheld pursuant to exemption Lot Number: C5474BA Dosage: 0.1mL (b)(6) (b)(7)(A): (b)(7)(C) Route: ID of the Freedom of Information and Privacy Act Exp Dt: 1012020 Comments: Tuberculosis: Hx of Previous Disease: No Blood-tinged Sputum: No Night Sweats: No Weight Loss: No Fever: No Cough:No Comments: Generated 07i0612019 21:56 by PA C Bureau of Prisons NYM Page 1 of 6 EFTA00073874 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] 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: Page 044 of 148 When Tested: 2019 Withheld pursuant to exemption Test Result: Negative When Diagnosed AIDS: (b)(6); (b)(7)(A): (b)(7)(C) Last CD4: of the Freedom of Information and Privacy Act 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 Page 2 of 6 EFTA00073875 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/0672019 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 Hx of Mental Health Treatment: None Hx of Head Injury: None Current Mental Health Treatment: No Current Mental Health Complaint: No Hx of Loss of Consciousness: No Hx of Hearing Voices: No Past History of Suicide Attempt: No Current Suicide Ideation: No Suicide Prevention Initiated:No Page 045 of 148 Comments: Withheld pursuant to exemption Substance Use History: Denied (b)(6); (b)(7)(A): (b)(7)(C) Current Painful Condition: Denied of the Freedom of Information and Privacy Act Other Health Issues: Current Medical Conditions: Other Current Treatments: Pregnant: N A Dental Condition: Denied Generated 07,06/2019 21:56 by PAC Bureau of Prisons NYM Page 3 of 6 EFTA00073876 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 07/06/2019 21:38 Provider: PA-C Reg #: Race: Facility: 76318-054 WHITE NYM Observations: Draining Skin Lesions: No Signs of Lice: No Signs of Scabies: No Signs of Recent Trauma: No Recent Tattoos: No Needle Marks: No Signs of Rash: No Open Sores: No Wounds: No Body Deformities: No Tremors: No Sweating: No Comments: Pulse: Date Time Rate Per Minute 07/06/2019 21:43 90 Respirations: Date Dme 07/06/2019 21:43 NYM Blood Pressure: Date Time Value Location 07/06/2019 21:45 NYM 164/90 Right Arm 07/06/2019 21:43 NYM 155/83 Left Arm SaO2: Date Time Value(%) Air 07/06/2019 21:43 NYM 95 Room Air Location Rhythm Provider Via Magbi006 of 148 Withheld pursuant to exemption Rate Per Minute Provider (b)SW ;41C7g),(ObblibRE ) of the Freedom of Information and Privacy Act Position Sitting Sitting Cuff Size Provider Adult-regular Adult-regular Provider Height: Date dm Inches Cm Provider 07/06/2019 21:43 NYM 72.0 182.9 PA-C Weight: Date Time the Kg Waist Circum Provider 07/06/2019 21:43 NYM 200.0 90.7 Prosthetic Devices/Equipment: Denied Potential Items For Follow-up: Item Travel Outside US Other Infectious Disease History Comments: I have reviewed 0 pages of intake paperworks PA-C PA-C PA-C PA-C PA-C Generated 07'06,2019 21:56 by PA-C Bureau of Prisons NYM Page 4 of 6 EFTA00073877 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Health Problems Newly Identified During This Encounter: HeatthEroblem Medication Reconciliation. The patient's known medication list including OTC items was compiled and compared to new and changed BOP orders. Reconciled Medications: Source Action Type Rx# Medication OTC No known OTCs Order Detail New Laboratory Requests: Details Frequency Due Date Priority Lab Tests-H-Hemoglobin A1C One Time 08/05/2019 00:00 Routine Lab Tests-C-CBC w/diff Lab Tests-L-Lipid Profile Lab Tests-C-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic Additional Information: 66 ylo male, elevated BP Labs requested to be reviewed by: New Non-Medication Orders: Page 047 of 148 Order Frequency .._Dumlloo Details . Ordered By withherb pursuant to exemption EKG One Time 66 yio male PA-C Order Date: 07'0612OO); (b)(7)(A); (b)(7)(C) Fecal Occult Blood One Time . 3 different stools of the Freedom of Information ana vrivacy ACT Order Date: 07/06,2019 Schedule: Activity Vision Screen 66 y/o male PPD Reading Follow-up BP check Date Scheduled Scheduled Provider 07/06/2019 00:00 Optometrist 07/08/2019 00:00 Nurse 07/09/2019 00:00 Mid-Level Provider Other: BP noticed to be elevated. IM denies Hx of HTN or any significant chronic medical conditions. He is currently asymptomatic and denies any bodily complaints at this time. Will recheck BP in 2-3 days. Disposition: Follow-up at Sick Call as Needed To be Evaluated by Provider Instructed inmate how to obtain medical, dental, and mental health care. Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No PA-C Generated 07'06:2019 21:56 by PA,C Bureau of Prisons NYM Page 5 of 6 EFTA00073878 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Completed by PA-C on 07/06/2019 21:56 Requested to be cosigned by Cosign documentation will be displayed on the following page. Page 048 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/06/2019 21:56 by PA•C Bureau of Prisons - NYM Page 6 of 6 EFTA00073879 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Cosigned with New Encounter Note by on 07/07/2019 00:17. Page 049 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073880 Bureau of Prisons Health Services History & Physical Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/201 953 Sex: Encounter Date: 07/09/2019 12:35 Provider M R e: WHITE Reg #: 76318-054 Facility: NYM Unit: H01 Seizures: Denied Diabetes: Denied Cardiovascular: Denied CVA: Denied Hypertension: Denied Respiratory: Denied Sickle Cell Anemia: Denied Carcinoma/Lymphoma: Denied Allergies: Denied Tuberculosis: Hx of Previous Disease: No Blood-tinged Sputum: No Night Sweats: No Weight Loss: No Fever: No Cough:No Comments: 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 Page 050 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07,09/2019 13:03 by Bureau of Prisons - NYM Page 1 of 13 EFTA00073881 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/09/2019 12:35 Provider: Reg #: 76318-054 Facility: NYM Unit: H01 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 Page 051 of 148 Comments: Chlamydia in 2015, treated Chicken pox in childhood Withheld pursuant to exemption Abuse History: Denied (b)(6) (b)(7)(A); (b)(7)(C) Physical: No Emotional: No Sexual: No Comments: Denies of the Freedom of Information and Privacy Act Generated 07,09/2019 13:03 by Bureau of Prisons - NYM Page 2 of 13 EFTA00073882 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: Unit: H01 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 Hx of Mental Health Treatment: None Hx of Head Injury: None Current Mental Health Treatment: No Current Mental Health Complaint: No Hx of Loss of Consciousness: No Hx of Hearing Voices: No Past History of Suicide Attempt: No Current Suicide Ideation: No Page 052 of 148 Suicide Prevention Initiated:No Comments: Withheld pursuant to exemption Substance Use History: Denied (b)(6); (b)(7)(A); (b)(7)(C) Current Painful Condition: DEtifiltib Freedom of Information and Privacy Act Other Health Issues: Current Medical Conditions: Other Current Treatments: Pregnant: N A Dental Condition: Denied Generated 07,09/2019 13:03 by Bureau of Prisons - NYM Page 3 of 13 EFTA00073883 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: Unit: H01 Observations: Draining Skin Lesions: No Signs of Lice: No Signs of Scabies: No Signs of Recent Trauma: No Recent Tattoos: No Needle Marks: No Signs of Rash: No Open Sores: No Wounds: No Body Deformities: No Tremors: No Sweating: No Comments: Page 053 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/09/2019 13:03 by Bureau of Prisons - NMI Page 4 of 13 EFTA00073884 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: Unit: H01 Immunizations: Hepatitis A and B (TwinRx) Series Administration: History Unknown, Not Administered Documented Date: 0709/2019 12:51 EST Immunization Date: Provider: Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Measles:Mumps,'Rubella Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: Page 054 of 148 Location: Withheld pursuant to exemption Drug Mfg: (b)(6) (b)(7)(A); (b)(7)(C) Lot Number: of the Freedom of Information and Privacy Act Dosage: Route: Exp Dt: Comments: Smallpox Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Tetanus Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Generated 07,09/2019 13:03 by Bureau of Prisons - NYM Page 5 of 13 EFTA00073885 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/09/2019 12:35 Provider: Reg #: 76318-054 Facility: NYM Unit: H01 Immunization Date: Provider: Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Varicella Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: Location: Drug Mfg: Lot Number: Page 055 of 148 Dosage: Withheld pursuant to exemption Route: (b)(6): (b)(7)(A); (b)(7)(C) Exp Dt: of the Freedom of Information and Privacy Act Comments: Temperature: Date Time Fahrenheit Celsius Location Provider 07/09/2019 12:49 NYM 97.3 36.3 Oral Pulse: PAW lime Rate Per Minute Location Rhythm Provider 07/09/2019 12:49 82 Via Machine Regular Respirations: Date Time Rate Per Minute Provider 07/09/2019 12:49 NYM 16 Blood Pressure: Date lime Value Location Position Cuff Size Provider 07/09/2019 12:49 NYM 117/66 Right Arm Sitting Adult-regular SaO2: Date Time Value(%) Air Provider 07/09/2019 12:49 NYM 97 Room Air Height: Date Time Inches Cm Provider 07/09/2019 12:49 NYM 70.0 177.8 Generated 07/09(2019 13:03 by Bureau of Prisons • NYM Page 6 of 13 EFTA00073886 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: Unit: H01 Date Time inches Cm Provider Weight: Date Time iLt s 07/09/2019 12:49 NYM 194.4 88.2 Prosthetic Devices1Equipment: Denied Tobacco Usage: Denied Kg Waist Circum. Provider General Social History: Foreign Travel: Born in USA: Yes Country of Birth: USA Patient Education Assessments: Date Ed Yrs Occupation Learns Best By Primary Language Barriers to Education 07/09/2019 12 Banker Speaking/Listening English None Family History - Father: Age at Death: 74 Cause of Death: Diabetes complications Significant Illnesses: Page 056 of 148 Diabetes Withheld pursuant to exemption Heart Disease Comments: (b)(6) (b)(7)(A): (b)(7)(C) Family History - Mother: of the Freedom of Information and Privacy Act Age at Death: 81 Cause of Death: Kidney Failure Significant Illnesses: Heart Disease Comments: Family History - Sibling: Number of Siblings: 1 Significant Illnesses: Comments: Past Hospitalization: Reason Location When Acute Appendicitis Mount Sinai Hospital 1990 Complications: None Comments: Head: Normal: Yes Comments: Generated 07/09(2019 13:03 by Bureau of Prisons - NYM Page 7 of 13 EFTA00073887 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: Unit: H01 Eyes: EOMI: Yes Icterus:No Conjunctival Inflammation: No Pupils Yes Pupil Size Rt: Pupil Size Lt: Pupils Comments: Fundi Vessels Nicking: No Fundi Vessels Discs Flat:Yes Fundi Vessels Discs Sharp Margins: Yes Fundi Vessels Grounds Abnormal: No Eyes Comments: Vision Screen Blindness: 07/09/2019 12:52 With Corrective Distance Vision: OD: 100 OS: 70 OU: OD: OS OU: Near Vision: OD: OS: OU: OD: OS: OU: Page 057 of 148 Ishihara Color Test: Withheld pursuant to exemption Tonometry: L: Comments: Needs evaluation with optometrist. Ears: Right Ear: Canal patent Left Ear: Canal patent Ears Comments: Nose: Nares Patent: Yes Septum Midline: Yes Septum Intact: Yes Drainage,Discharge: No Polyps: No Nose Comments: (b)(6). (b)(7)(A). (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07,09/2019 13:03 by Bureau of Prisons - NYM Page 8 of 13 EFTA00073888 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: HITE Encounter Date: 07/09/2019 12:35 Provider: Reg #: 76318-054 Facility: NYM Unit: H01 Mouth Lesions:No Oral/Buccal Mucosa:Yes Gums Normal: Yes Tonsils Present:Yes Tonsils Normal: Yes Pharynx: Normal Color Teeth Poor Dentition: No Teeth Count:Mostly Present Dentures: No Mouth Comments: Cranial Nerves: Intact Yes Cranial Nerves Comments: Neck: Full ROM:Yes Masses Nodes: No Trachea: Midline Thyroid: Normal Size Comments: Breasts: Page 058 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Normal: Yes Masses:No Tenderness:No Scars: No Dimpling:No Nipple Discharge: No Nipple Retraction:No Instructions for Self Breast Exam Given: Comments: No Generated 07,09/2019 13:03 by Bureau of Prisons - NYM Page 9 of 13 EFTA00073889 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 07/09/2019 12:35 Provider M R : WHITE Reg #: 76318-054 Facility: NYM Unit: H01 Thorax: Contour Normal:Yes Increased AP Diameter: No Asymmetrical Expansion:No Lungs Clear: Yes Wheezes: No Crackles: No Rhonchi: No Rates: No Accessory Muscle Use: No Comments: Spine: Deformity: No Full ROM:Yes Tenderness: No Comments: Cardiovascular: Page 059 of 148 RRR: Yes Withheld pursuant to exemption Normal S1/S2: Yes Murmurs: No (b)(6); (b)(7)(A): (b)(7)(C) Carotid Bruits: No of the Freedom of Information and Privacy Act JVD: No Arteries: Right Left Radial: Femoral: Dorsalis Pedis: Post. Tibialis: Comments: Generated 07,0912019 13:03 by Bureau of Prisons - NYM Page 10 of 13 EFTA00073890 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 07/09/2019 12:35 Provider HITS Reg 4: 76318-054 Facility: NYM 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 Page 060 of 148 Lower Extremity Edema - Left: None Atrophy: No Withheld pursuant to exemption Amputations: No (b)(6) ; (b)(7)(A); (b)(7)(C) Other Deformities: No Varicosities:No of the Freedom of Information and Privacy Act Calf Tenderness:No Pulse Deficit: No Strength: Right Left Arm: Leg: Full ROM: Right Left Arm: Yes Yes Leg: Yes Yes Comments: Generated 07,09/2019 13:03 by Bureau of Prisons - NYM Page 11 of 13 EFTA00073891 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: Encounter Date: 07/09/2019 12:35 Provider M R : WHITE Reg #: 76318-054 Facility: NYM Unit: H01 Reflexes: Right ken 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: Item Travel Outside US Page 061 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A), (b)(7)(C) of the Freedom of Information and Privacy Act Other Infectious Disease History Rectum Not Done Male Genitalia Not Done PPD Administration Not Performed Comments: Patient has a history of constipation. Generated 07,0912019 13:03 by Bureau of Prisons Page 12 of 13 EFTA00073892 Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/09/2019 12:35 Provider: Reg #: 76318-054 Facility: NYM Unit: H01 Cleared For Food Services: Yes Health Problems Newly Identified During This Encounter: Health Problem Constipation, unspecified - Current - New Medication Orders: Rx# MedicaliO_n Order Date PreS.Criber Ogler Bisacodyl E.C. Tablet 07/09/2019 12:35 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 TelephoneNerbal Order: No Completed by Requested to be cosigned by Cosign documentation will be displayed on the following 062 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Cosign Required: Yes on 07 09 2019 13:03 Generated 07,09/2019 13:03 by Bureau of Prisons - NYM Page 13 of 13 EFTA00073893 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Encounter Date: 07/09/2019 12:35 Provider: Facility: NYM Cosigned by on 07/11/2019 22:41. Page 063 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073894 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 RIO self inflicted injuries. Body mass index (BMI) 27.0-27.9, adult Current Medications: All medications to be continued until evaLuage ate °tw d Joyoaphysician unless otherwise indicated. P ? Bolded drugs required for transport. Docusate Sodium 100 MG Cap Exp: 08/11/264M-AO.pTiSafietbcattroilftia00 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 (b)(6), (b)(7)(A), (b)(7)(C) Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML Exp: 10/28/2019 SIG: shake well take 10ml by mouth twice daily AS NEEDED of the Freedom of Information and Privacy Act 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 Dale 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 Date Frequency 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: TB Treatment: TB Follow-up Recommended: No Sickle Cell: Sickle Cell Trait/Disease: No Results: Sx free for 30 days: Yes Generated 08..10;2019 07:00 by RN Bureau of Prisons NYM Page 1 of 2 EFTA00073895 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD SENSITIVE BUT UNCLASSIFIED - This information is confidential and must be appropriately safeguarded. Limitations/Restrictions/Diets: Cell: lower 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 Address 1: Address 2: City/State/Zip: NEW YORK. New York 10007 Name/Title of Person Completing Form: Inmate Name: EPSTEIN, JEFFREY EDWARD Phone Number: RN Date: 08/10/2019 Re ag deglf-P134 DOB [DOB REDACTED] Sex: M Withheld pursuant to exemption (b)(6); (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Generated 08r10/2019 07:00 by RN Bureau of Prisons NYM Page 2 of 2 EFTA00073896 Bureau of Prisons Health Services Vitals All Begin Date: 07/06/2019 Reg #: 76318-054 End Date: 05/11/2020 Inmate Name: EPSTEIN, JEFFREY EDWARD Temperature: Date 07/24/2019 Time Fahrenheit 13:12 NYM 97.8 Celsius Location Provider 36.6 Oral Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 NYM 97.5 36.4 Oral Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM 97.3 36.3 Oral Orig Entered: 07/09/2019 12:51 EST Pulse: Date Time 07/30/2019 13:02 Rate Per Minute Location Rhythm Provider 94 Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:40 88 Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:30 87 Orig Entered: 07/28/2019 20:28 Orig Entered: 07/28/2019 06:57 Orig Entered: 07/24/2019 13:12 Orig Entered: 07/23/2019 06:30 Orig Entered: 07/09/2019 12:49 Orig Entered: 07/06/2019 21:43 Orig Entered: Respirations: Date 07/30/2019 Orig 07/28/2019 Orig 07/28/2019 Orig 07/23/2019 Orig 07/09/2019 Via Machine Via Machine 07/30/2019 12:59 EST Beaul349014%thhieD pursuant to "'remotion 07/28/2019 20:29 EST L RN 82 (b)(6): (b)(7)(A): (b)(7)(C) 07/28/201:#04:flet4Tm gfzibielCi9atikthstiRti lacy Act 83 Via Machine Regular 07/24/2019 13:14 EST 92 Via Machine Regular 07/23/2019 08:33 EST 82 Via Machine Regular 07/09/2019 12:51 EST 90 Via Machine 07/06/2019 21:48 EST PA-C Time 09:30 NYM Rate Per Minute Provider Entered: 07/30/2019 12:59 EST 20:28 NYM 12 14 RN Entered: 07/28/2019 20:29 EST RN 06:57 NYM 14 RN Entered: 07/28/2019 06:58 EST RN 06:30 NYM 16 Entered: 07/23/2019 08:33 EST • 12:49 NYM 16 PA-C RN RN Generated 05/11/2020 09:57 by OGC Bureau of Prisons • DAN Page 1 of 3 EFTA00073897 Begin Date: 07/06/2019 Reg #: 76318.054 End Date: 05/11/2020 Inmate Name: EPSTEIN, JEFFREY EDWARD Generated 05/11/2020 09:57 by Date Time Rate Per Minute Provider Orig Entered: 07/09/2019 12:51 EST 07/06/2019 21:43 NYM 15 PA-C Orig Entered: 07/06/2019 21:48 EST PA-C Blood Pressure: Date lime Value 07/30/2019 13:02 NYM 114/84 Orig Entered: 07/30/2019 09:40 NYM Orig Entered: 07/30/2019 09:30 NYM Orig Entered: 07/28/2019 20:28 NYM Orig Entered: 07/28/2019 06:57 NYM Orig Entered: 07/24/2019 13:12 NYM Orig Entered: 07/23/2019 06:30 NYM Orig Entered: 07/09/2019 12:49 NYM Orig Entered: 07/06/2019 21:45 NYM Orig Entered: 07/06/2019 21:43 NYM Orig Entered: Blood Glucose: Date Time 08/04/2019 08:30 Orig Entered: 08/02/2019 06:30 Orig Entered: 08/01/2019 06:30 Location Position Cuff Size Provider Left Arm Standing 07/30/2019 13:04 EST 125/60 Right Arm Standing 07/30/2019 13:04 EST 108/86 Left Arm Sitting 07/30/2019 12:59 EST 157/91 07/28/2019 20:29 EST RN 138/80 07/28/2019 06:58 EST RN 132/89 Right Arm Sitting Adult-regular 07/24/2019 13:14 EST 140/85 Right Arm 067 of 148"un-regular 07/23/2019 08:33 EST 117/66 Right Pre %lair o exenli8n. u reg lar 07/09/2019 12:51 ESTO:464g(Ii0(704914b)(7)(C) 164/90 RiVt Arm Sitting. Adult-regular 07/06/201)9 t21:41;egtr $an8Privacy Act 155/83 Left Arm 07/06/2019 21:48 EST Sitting Value (mg/dO type 156 Non-Fasting 08/04/2019 09:08 EST 97 Non-Fasting 08/02/2019 08:16 EST 103 Non-Fasting Orig Entered: 08/01/2019 09:00 EST Adult-regular PA-C 07/31/2019 06:15 108 Non-Fasting Orig Entered: 07/31/2019 08:36 EST Sa02: Date 07/30/2019 lime Value(%) Air 09:30 NYM 98 Room Air Orig Entered: 07/30/2019 12:59 EST 07/28/2019 20:28 NYM 98 Orig Entered: 07/28/2019 20:29 EST 07/28/2019 06:57 NYM 98 OGC PA-C PA-C Regular Insulin Provider RN Provider Bureau 01 Prisons • DAN RN RN RN RN RN RN Page 2 of 3 EFTA00073898 Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318.054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date Time Value(%) Air Provider Orig Entered: 07/28/2019 06:58 EST RN 07/24/2019 13:12 NYM 96 Room Air Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 NYM 96 Room Air Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM 97 Room Air Orig Entered: 07/09/2019 12:51 EST 07/06/2019 21:43 NYM 95 Room Air Orig Entered: 07/06/2019 21:48 EST PA-C Height: Date lime Inches Cm Provider 07/09/2019 12:49 NYM 70.0 177.8 Orig Entered: 07/09/2019 12:51 EST 07/06/2019 21:43 NYM 72.0 182.9 Orig Entered: 07/06/2019 21:48 EST PA-C PA-C PA-C Weight: Date Time the Kg Waist Circum. Provider 07/30/2019 09:30 NYM 194.2 88.1 Page 068 oinadouin, Robert MD Orig Entered: 07/30/2019 12:59 Reahhaelamaiscial RobleMpffibn 07/09/2019 12:49 NYM 194.4 88.2 (b)(6 Ha 7 A; Orig Entered: 07/09/2019 12:51 EST 07/06/2019 21:43 NYM 266.81e FroWyrn o ormation angeritaiMWA-C Orig Entered: 07/06/2019 21:48 EST PA-C Generated 05/11/2020 09:57 by OGC Bureau of Prisons • DAN Page 3 of 3 EFTA00073899 Bureau of Prisons Health Services PPDs Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Admin: Location 07/06/2019 21:39 Right Forearm Orig Entered: 07/06/2019 21:43 EST Total: 1 Provider PA-C PA-C Reading• Induration Provider 07/09/2019 12:47 0 mm Orig Entered: 07/09/2019 12:47 EST Page 069 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Generaled 05/11/2020 09:57 by OGC Bureau of Prisons DAN Page 1 of 1 EFTA00073900 76316054 EPSTEIN. JEFFREY Medication Orders Medication Administration Record JULY 2019 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. Date 0730'19 I4 21 Inject regular insulin subcutaneously per Exp. Dale sliding scale: twice daily "'pill 'Inc— for 7 0731/9 days '0.01 NYM 122148- NYM Insulin Rog (10 ML) 100 UNITSML Ws inIN Ord. Date 07/31/19 '0:00 Inject regular insulin subcutaneously per Exp. Date sliding scale: each morning for 7 days "'pill 08.07/9 Ilne—• 09 59 NYM 122160- NYM InSoto Reg (10 ML) 100 UNITSSAL In1 1111N Panp 0T0 of US Withheld pursuant to exemption (b)(6) ; (b)(7)(A) : (b)(7)(C) of the Freedom of Information and Privacy Act Providers: YJ Documentation Codes: ORD = Order I NI = Dose Not Indicated Registration F. 76318-054 Pt. Name: EPSTEIN. JEFFREY DOB: 01/20153 Report information is current as of the date and time of printing: 05,11-2020 09:57 EST EFTA00073901 76318-054 EPSTEIN. JEFFREY Medication Orders Medication Administration Record AUGUST 2019 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. Date 0731,19 10 00 Exp. Dale 08,07,19 09:59 Inject regular insulin subcutaneously per sliding scale: each morning for 7 days —pill line— NYM 122160 NYM Insuim Rog (10 ML) 100 UNITS ML Iq PAN Page 071 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A) : (b)(7)(C) of the Freedom of Information and Privacy Act Providers: Y..1 = Documentation Codes: ORD = Order I NI = Dose No1 Indicated Registration 4. 76318-054 Pt. Name: EPSTEIN. JEFFREY DOB: 01:20:53 Report information is current as of the date and time of printing: 05:11,2020 09:57 EST EFTA00073902 Bureau of Prisons Health Services Devices and Equipment Start Date: 07/06/2019 Stop Date: 05/11/2020 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Device/Equipment Stan Date Stop Date Date Returned Obtained From Comments C-Pap 07/30/2019 14:05 EST 07/30/2019 Personal PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Total: 1 Page 072 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 05/11/2020 09:57 by OGG Bureau of Prisons - DAN Page 1 of 1 EFTA00073903 Bureau of Prisons Health Services Pain Management Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Date Intervention 07/12/2019 13:25 MEDROL DOSE PACK Orig Entered: 07/12/2019 13:28 EST Pain Quality Shooting Page 073 of 148 Withheld pursuant to exemption (b)(6) : (b)(7)(A) : (b)(7)(C) of the Freedom of Information and Privacy Act Location Pre Post Provider Back-Middle 5 Generals 0511;2020 0937 by OGG Bureau of Prisons DAN Page 1 of 1 EFTA00073904 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: Page 074 of 148 EPSTEIN. JEFFREY EDWARD Inmate Name Withheld pursuant to exemption (b)(6); (b)(7)(A): (b)(7)(C) Health Service Staff of the Freedom of Ini&AH;4and Privacy Act 07/30/2019 Reg# Date Generated 07/30/2019 14:57 by Bureau of Prisons NYM Page 1 of 1 EFTA00073905 Bureau of Prisons Health Services Allergies Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Alleray No Known Allergies Orig Entered: Total: 1 07/06/2019 21:40 EST Date Noted Reaction 07/06/2019 PA-C Page 075 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Generated 05/11/2020 09:57 by OGC Bureau of Prisons - DAN Page 1 of 1 EFTA00073906 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 Date Initiated Form Handout/Topic Outcome Provider 07/30/2019 Counseling Access to Care Verbalizes Understanding Orig Entered: 07/30/2019 13:33 EST Page 076 of 148 07/30/2019 Counseling Plan of Care Withheld pursuant to exempliobalizes Understanding Orig Entered: 07/30/2019 13:34 EST (b)(6); (b)(7)(A) : (b)(7)(C) 07/28/2019 Counseling Plan of Verbalizes Understanding om of Information and Privacy Act 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 05'1112020 09:57 by OGC Bureau of Prisons DAN Page 1 of 2 EFTA00073907 Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Topics Date Initiated Format Handout/Topic Outcome Provider Orig Entered: 07/12/2019 13:33 EST Total: 10 Page 077 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 0511 2020 0937 by OGC Bureau of Prisons DAN Page 2 ol 2 EFTA00073908 Bureau of Prisons Health Services Blood Glucose Begin Date: 07/06/2019 Reg #: 76318-054 End Date: 05'11:2020 Inmate Name: EPSTEIN. JEFFREY EDWARD (Reference Range: Random or Fasting 70 - 100.2 hour post-prandial 70 - 140) Date Time Value Type 08/0412019 08:30 NYM 156 Orig Entered: 08/04/2019 09:08 EST 08/02/2019 06:30 NYM 97 Orig Entered: 08/02/2019 08:16 EST 08/01:2019 06:30 NYM 103 Orig Entered: 08/01/2019 09:00 EST 07:31:2019 06:15 NYM 108 Orig Entered: 07/31/2019 08:36 EST Total: 4 Non-Fasting RN Non-Fasting Non-Fasting Non-Fasting Comments Page 078 of 148 Withheld pursuant to exemption (b)(6): (b)(7)(A) : (b)(7)(C) of the Freedom of Information and Privacy Act Generated 05(11/2020 09:57 by OGC Bureau of Prisons DAN Page I of 1 EFTA00073909 Bureau of Prisons Health Services Health Problems Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Description Hyperlipidemia, unspecified 07/12/2019 13:48 EST HYPERTRIGLYCERIDEMIA Sleep apnea 07/12/2019 13:56 EST Essential (primary) hypertension 07/30/2019 13:13 EST BY HX. Constipation, unspecified 07/09/2019 12:58 EST Low back pain 07/12/2019 13:30 EST Neuralgia and neuritis, unspecified 07/12/2019 13:30 EST No Diagnosis 07/09/2019 10:28 EST PhD/Chief Psychologist Prediabetes 07/30/2019 13:26 EST Injury, unspecified 07/23/2019 09:04 EST to self inflicted injuries. Body mass index (BMI) 27.0.27.9, adult 07/30/2019 13:14 EST Total: 10 Current Axis Code Type Code Diag. Date Status ICD-10 E785 07/12/2019 Current ICD-10 G4730 07/12/2019 Current ICD-10 110 07/30/2019 Current Page 079 of .1! iuu 10 K5900 07/09/2019 Current Withheld pursuant to exemption (b)(6); (b)(7)(A): (WA M545 07/12/2019 Current of the Freedom of Information and Privacy Act ICD-10 M792 07/12/2019 Current I DSM-IV No Dx 07/09/2019 Current ICD-10 R7303 07/30/2019 Current ICD-10 T1490 07/23/2019 Current ICD-10 Z6827 07/30/2019 Current Status Date Generated 05/11/2020 09:57 by OGC Bureau of Prisons - DAN Page 1 of EFTA00073910 Bureau of Prisons Health Services Vision Screens Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Vision Screen on 07/09/2019 12:52 Blindness: Distance Vision: OD: 20/100 OS: 20/70 OU: Near Vision: OD: OS: OU: With Corrective Distance Vision: OD: OS: OU: Near Vision: OD: OS: OU: Present Glasses - Distance Refraction - Distance Sphere Cylinder Axis Add Sphere Cylinder Axis Add L: L: Color Test: Tonometry: L: Comments: Needs evaluation with optometrist. Orig Entered: 07/09/2019 12:54 EST e 080 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 05/11/2020 09:57 by OGC Bureau of Prisons • DAN Page 1 of 1 EFTA00073911 Bureau of Prisons Health Services Immunizations Begin Date: 07/06/2019 End Date: 05'11:'2020 Reg It: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD immunization Immunization Date Administered Location Dosage Drug Mfg Lot # Exp Date Hepatitis A and B (TwinRx) History Unknown Orig Entered: 07/09/2019 12:51 EST Measles/Mumps,Rubella Series History Unknown Orig Entered: 07/09/2019 12:51 EST Smallpox Series History Unknown Orig Entered: 07/09/2019 12:51 EST Tetanus History Unknown Orig Entered: 07/09/2019 12:51 EST Varicella Series History Unknown Orig Entered: 07/09/2019 12:51 EST Total: 5 Page 081 of 148 Withheld pursuant to exemption (b)(6) : (b)(7)(A) : (b)(7)(C) of the Freedom of Information and Privacy Act Generated 05111/2020 09:57 by OGC Bureau of Prisons DAN Page 1 of I EFTA00073912 Bur ^. Prisons i-lea:`!I Services iCqc .cal Duty Status Reg #: 76318-054 in :ate Name: EPSTEIN. JEFFREY EDWARD Housing Status confined to the living quarter: t. ', ept _meals pill line treatments Exp. Date: _ _ on complete bed rest: bathroom privileges only Exp. Date: _ X cell: _cell on fir . floc, single cell X lower bunk airborne infection isolation Exp. Date: 19: 019 other: Exp. Date: Physical Limila: 1/Restriction all spc s Hill. 4: upper body lower body CP die ascular exercise: running _jogging walking softball football basketball handball stationary er ..-ment other: Exp. L. le: F .n. Date: Eap. Date: Exp. Date: May have the following equipment in his / her possession: Equipment Start C ite End Date Return Date C-Pap 07 ni 19 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Page 082 of 148 Work Restriction / Limitation: Cleared for Food Service: Yes X No Restrictions Comments: N/A Withheld pursuant to exemption (b)(6) (b)(7)(A) (b)(7)(C) of the Freedom of Information and Privacy Act Health Services Staff 07/30/2019 Date Inmate Name: EPSTEIN, ."3-. -WY EDWARD Reg #: 76318-054 Quarters: null ALL EXPIRATION DATES ctt .F 24:00 Generated 05/11/2020 09:57 by OGC C of Prisons - DAN Page I of 1 EFTA00073913 Bur :Lit ^. Prisons l-lea:`!I Services ih'qc .cal Duty Status Reg #: 76318-054 in. :ate Name: EPSTEIN. JEFFREY EDWARD Housing Status confined to the living quarter:. t., ept _meals pill line treatments Exp. Date: on complete bed rest: bathroom privileges only Exp. Date: X cell: cell on fir' floc, single cell X lower bunk airborne infection isolation Exp. Date: 4 0.19/ :019 other: Exp. Date: Physical Limlio: VRestriction all spc s Exp. L. le: wr 4h upper body lower body F • n. Date: ca dic ascular exercise: _running _jogging walking softball Eat.). Date: football basketball handball stationary er ..-ment other: May have the following equipment in his / her possession: Work Restriction / Limitation: Cleared for Food Service: Yes X No Restrictions Comments: N/A Health Services Staff Page 083 of 148 Withheld pursuant to exemption (b)1b). (b)(/)(A), (b)( O(L) Exp. Date: 07/09/2019 Date Inmate Name: EPSTEIN, JEFFREDYtEEPtieed6M of lifferation alf3318#0&14Act Quarters: null ALL EXPIRATION DATES ARE ATI' ,..01 Generated 05/11/2020 09:57 by OGC Eure;i:i of Prisons - DAN Page I of 1 EFTA00073914 Bureau of Prisons Health Services Medication Summary Historical Complex: NYM--NEW YORK MCC Inmate: EPSTEIN. JEFFREY EDWARD Begin Date: 07/06:2019 End Date: 05/11/2020 Reg #: 76318.054 Quarter: ???-???? Medications listed reflect prescribed medications from the begin date to end date on this report. Allergies: Denied Active Prescriptions Bisacodyl E.C. 5 MG TAB Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10 days Rx#: 121757-NYM Doctor: Start: 07/09/19 Exp: 0719119 D/C: 07/12/19 Pharmacy Dispensings: 10 TAB in 307 days Docusate Sodium 100 MG Cap Take one capsule (100 MG) by mouth twice daily for 30 days Rx#: 121823-NYM Doctor: Start: 07/12/19 Exp: 08/11/19 D/C: 08/10/19 Pharmacy Dispensings: 60 CAP in 304 days Page 084 of 148 Docusate Sodium 100 MG Cap Take one capsule (100 MG) twice daily by moutkVittthet&PU9s0lAktcteexemption Rx#: 122084-NYM Doctor: Beaudouin. RobwW (b)(7)(A); (b)(7)(C) Start: 07/26/19 Exp: 01/22/20 D/C: 0810119 Pharmacy Dispensings: 30 CAP in 290 days of the Freedom of Information and Privacy Act Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML shake well take 2 tablespoonful twice daily by mouth Rx#: 121835-NYM Doctor: Start: 07/12/19 Exp: 07/14/19 Pharmacy Dispensings: 473 ML in 304 days Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML shake well take 10ml by mouth twice daily AS NEEDED Rx#: 122150-NYM Doctor: Start: 07/30/19 Exp: 10/28/19 D/C: 08/10/19 Pharmacy Dispensings: 473 ML in 286 days methylPREDNISolone 4 MG Tab [ 21 count Pack] Take the tablet by mouth as directed Rx#: 121836-NYM Doctor: Start: 07/12/19 Exp: 07/18/19 methylPFIEDNISolone 4 MG Tab [ 21 count Pack] Take the tablet by mouth as directed Rx#: 122149-NYM Doctor: Start: 07/30/19 Exp: 08/05/19 Pharmacy Dispensings: 21 tab in 304 days Pharmacy Dispensings: 21 tab in 286 days Generated 05:11)2020 09:57 by OGC Bureau of Prisons DAN Page 1 of 2 EFTA00073915 Complex: NYM--NEW YORK MCC Inmate: EPSTEIN, JEFFREY EDWARD Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318-054 Quarter: ???-???? Active Prescriptions Omega 3 (Vascepa) 1 GM Capsule Take two capsules (2 GM) twice daily by mouth with food Rx#: 121885-NYM Doctor: Start: 07/17/19 Exp: 01/13/20 D/C: 08/10/19 Pharmacy Dispensings: 180 Cap in 299 days Insulin Reg (10 ML) 100 UNITS/ML Inj Inject regular insulin subcutaneously per sliding scale: twice daily "'pill line"' for 7 days —pill line— Rx#: 122148-NYM Doctor: Start: 07/30/19 Exp: 08/06/19 D/C: 07/31/19 Pharmacy Dispensings: 0 ML in 286 days Insulin Reg (10 ML) 100 UNITS/ML Inj Inject regular insulin subcutaneously per sliding scale: each morning for 7 days "'pill line"' "'pill line*" Rx#: 122160-NYM Doctor: Start: 07/31/19 Exp: 08/07/19 Pharmacy Dispensings: 0 ML in 285 days Page 085 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 05/11/2020 09:57 by OGC Bureau of Prisons - DAN Page 2 of 2 EFTA00073916 Bureau of Prisons Health Services Dental Health History Screen Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Facility: NYM Encounter Date: 07/26/2019 07:54 Provider: DDS Unit: H01 ASSESSMENTS: Health Problems as of Dental Health History Encounter date: 07/26/2019 07:54 Health Problems Health Problem Status Hyperlipidemia, unspecified Current HYPERTRIGLYCERIDEMIA Sleep apnea Current Constipation, unspecified Current Low back pain Current Neuralgia and neuritis, unspecified Current No Diagnosis Current Injury, unspecified Current RIO self inflicted injuries. Medical History as of Dental Health History Encounter date: 07/26/2019 07:54 Medical History: Allergies: Denied Page 086 of 148 Seizures: Denied Withheld pursuant to exemption Diabetes: Denied Cardiovascular: Denied (b)(6); (b)(7)(A); (b)(7)(C) CVA: of Ehefeeledom of Information and Privacy Act Hypertension: Denied Respiratory: Denied Sickle Cell Anemia: Denied Carcinoma/Lymphoma: Denied HIV History: When Tested: 2019 Test Result: Negative When Diagnosed AIDS: Last CD4: Comments: Hepatitis: Denied Generated 07,26/2019 07:59 by DDS Bureau of Prisons NYM Page 1 of 3 EFTA00073917 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth [DOB REDACTED] Sex: M Race: WHITE Facility: NYM Encounter Date: 07/26/2019 07:54 Provider: DDS Unit: H01 Other Infectious Diseases: Syphilis: Syphilis Last Treatment: Genital Warts: Chlamydia: Gonorrhea: Herpes: Chicken Pox: Other: No N/A No Yes No No Yes No Comments: Chiamydia in 2015. treated Chicken pox in childhood Other Health Issues: Other Medical Conditions And Treatment:sleep apnea Current Medical Conditions: Other Current Treatments: Pregnant: N A Dental Observations as of Dental Health History EncouRglecRARO/R/2019 07:54 Alcohol: Methamphetamine: Tobacco products: Other drugs: Sensitive teeth: Bleeding gums: Food impaction: Pain around ear: Toothache: Wear partial dentures: Unusual sounds while eating: Snoring: Blisters on lips or mouth: Clenching or grinding: Swelling or lumps in mouth throat: Burning tongue: Bad breath: HiStinWVithhel