# Bureau of Prisons
Health Services
Clinical Encounter

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/12/2019 13:10

Sex:
Provider:

M Race: WHITE

Reg #: 76318-054
Facility: NYM
Unit: Z05

# Bureau of Prisons
Health Services
Clinical Encounter (cont.)

Chronic Care 14 Day Physician Eval encounter performed at Health Services.

SUBJECTIVE:

HYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS

800, NOW 434. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE

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.

L4-L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE

COMPLAINT 1 Provider:

Chief Complaint: ENDO/LIPID
Subjective: 66 YR OLD WHITE MALE WITH HX OF

MEDS DUE TO THEIR GI SIDE EFFECTS.

STATES THE FBI LOKELY HAS

LOWER EXTREMITIES.
SURGICAL HX: NONE
MENTAL HEALTH HX: NONE
Pain: Yes

Pain Assessment
Date: 07/12/2019 13:25

Location: Back-Middle

Quality of Pain: Shooting

Pain Scale: 5

Intervention: MEDROL DOSE PACK

Trauma Date/Year:

Injury:

Mechanism:

Onset: 5+ Years

Duration: 5+ Years

Exacerbating Factors: NO EXERCISE

Relieving Factors: MEDROL DOSE PACK

Reason Not Done:

Comments:

Amendment

Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology

# Bureau of Prisons
Health Services
Clinical Encounter (cont.)

## 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

CONFIDENTIAL

SDNY 00009419
EFTA00034950

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/12/2019 13:10

Sex:
Provider:

M Race: WHITE

Reg #: 76318-054
Facility: NYM
Unit: Z05

Exam:

Eyes
General
Yes: PERRLA, Extraocular Movements Intact

Pulmonary
Auscultation
Yes: Clear to Auscultation

Cardiovascular
Auscultation
Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2
No: M/R/G
Abdomen
Auscultation
Yes: Normo-Active Bowel Sounds

Palpation
Yes: Within Normal Limits

Musculoskeletal
Tibia / Fibula

No: Edema
Back
Yes: Tenderness See Amendment

Neurologic
Cranial Nerves (CN)
Yes: Within Normal Limits

Motor System-General
Yes: Normal Exam

ASSESSMENT:

Constipation, unspecified, K5900 - Current

Hyperlipidemia, unspecified, E785 - Current

Low back pain, M545 - Current

Neuralgia and neuritis, unspecified, M792 - Current

Sleep apnea, G4730 - Current

# Bureau of Prisons
Health Services
Clinical Encounter (cont.)

## OBJECTIVE: (cont.)

PLAN:

New Medication Orders:

<table><tr><th>New</th><th>Medication</th><th>Orders:</th><th></th><th></th></tr><tr><td>Rx#</td><td></td><td>Medication</td><td>Order Date</td><td>Prescriber Order</td></tr><tr><td></td><td></td><td>Magnesium Hydroxide Susp</td><td>07/12/2019 13:10</td><td>30 CC Orally Two Times a
Day PRN x 2 day(s)</td></tr><tr><td></td><td></td><td>Indication: Constipation, unspecified
MethylPREDNISolone Tab 4 MG (Dose
Pack 21 tab)</td><td>07/12/2019 13:10</td><td>AS DIRECTED Orally daily x
6 day(s)</td></tr><tr><td></td><td colspan="3">Indication: Neuralgia and neuritis, unspecified</td><td></td></tr></table>

Disposition:

Generated 07/12/2019 14:20 by



Bureau of Prisons - NYM

Page 2 of 3

CONFIDENTIAL

SDNY 00009420
EFTA00034951

# Bureau of Prisons
Health Services
Clinical Encounter (cont.)

## OBJECTIVE: (cont.)

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/12/2019 13:10

Sex:
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 Provider Outcome
07/12/2019 Counseling Diagnosis Verbalizes
Understanding

Copay Required: No Cosign Required: No
Telephone/Verbal Order: No

Completed by Beaudouin, Robert MD on 07/12/2019 14:20

See Amendment

Generated 07/12/2019 14:20 by

Bureau of Prisons - NYM

Page 3 of 3

# CONFIDENTIAL

SDNY 00009421
EFTA00034952

Bureau of Prisons
Health Services

# Clinical Encounter

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/12/2019 13:10

Sex:
Provider:

M Race: WHITE

Reg #: 76318-054
Facility: NYM
Unit: Z05

# Clinical Encounter (cont.)

Chronic Care 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE:



COMPLAINT 1 Provider:

Chief Complaint: ENDO/LIPID

Subjective:

66 YR OLD WHITE MALE WITH HX OF

HYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS

800, NOW 434. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE

MEDS DUE TO THEIR GI SIDE EFFECTS.

HX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP

MACHINE. STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED.

STATES THE FBI LOKELY HAS

L4-L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE

LOWER EXTREMITIES.

SURGICAL HX: NONE

MENTAL HEALTH HX: NONE

Pain:

Yes

Pain Assessment

Date: 07/12/2019 13:25

Location: Back-Middle

Quality of Pain: Shooting
Pain Scale: 5

Intervention: MEDROL DOSE PACK

Trauma Date/Year:

Injury:

Mechanism:

Onset: 5+ Years

Duration: 5+ Years

Exacerbating Factors: NO EXERCISE

Relieving Factors: MEDROL DOSE PACK
Reason Not Done:

Comments:

Amendment

Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology

# Clinical Encounter (cont.)

## 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

CONFIDENTIAL

SDNY 00009422
EFTA00034953

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/12/2019 13:10

Sex:
Provider:

M Race: WHITE

Reg#: 76318-054
Facility: NYM
Unit: Z05

Exam:

Eyes
General
Yes: PERRLA, Extraocular Movements Intact

Pulmonary
Auscultation
Yes: Clear to Auscultation

Cardiovascular
Auscultation
Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2
No: M/R/G
Abdomen
Auscultation
Yes: Normo-Active Bowel Sounds

Palpation
Yes: Within Normal Limits

Musculoskeletal
Tibia / Fibula

No: Edema
Back
Yes: Tenderness See Amendment
Neurologic
Cranial Nerves (CN)
Yes: Within Normal Limits

Motor System-General
Yes: Normal Exam

ASSESSMENT:

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:

Rx#

# Clinical Encounter (cont.)

## OBJECTIVE: (cont.)

<table><tr><th>New</th><th>Medication</th><th>Orders:</th><th></th><th></th></tr><tr><td>Rx#</td><td></td><td>Medication</td><td>Order Date</td><td>Prescriber Order</td></tr><tr><td></td><td></td><td>Magnesium Hydroxide Susp</td><td>07/12/2019 13:10</td><td>30 CC Orally Two Times a
Day PRN x 2 day(s)</td></tr><tr><td></td><td></td><td>Indication: Constipation, unspecified
MethylPREDNISolone Tab 4 MG (Dose
Pack 21 tab)</td><td>07/12/2019 13:10</td><td>AS DIRECTED Orally daily x
6 day(s)</td></tr><tr><td></td><td colspan="3">Indication: Neuralgia and neuritis, unspecified</td><td></td></tr></table>

Disposition:

Generated 07/12/2019 14:20 by



Bureau of Prisons - NYM

Page 2 of 3

CONFIDENTIAL

SDNY 00009423
EFTA00034954

# Clinical Encounter (cont.)

## OBJECTIVE: (cont.)

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/12/2019 13:10

Sex:
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 Provider Outcome
07/12/2019 Counseling Diagnosis Verbalizes
Understanding

Copay Required: No Cosign Required: No
Telephone/Verbal Order: No

Completed by on 07/12/2019 14:20

ee Amendment

Generated 07/12/2019 14:20 by

Bureau of Prisons - NYM

Page 3 of 3

# CONFIDENTIAL

SDNY 00009424
EFTA00034955

# Bureau of Prisons
Health Services
See Amendment

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953 Sex: M
Encounter Date: 07/14/2019 17:36

Reg #: 76318-054
Race: WHITE
Facility: NYM

Amendment made to this note by

on 07/14/2019 18:11.

Bureau of Prisons - NYM

# CONFIDENTIAL

SDNY 00009425
EFTA00034956

# Bureau of Prisons
Health Services

# Clinical Encounter - Administrative Note

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Note Date: 07/12/2019 09:06

Sex: M Race WHITE
Provider:

Reg #: 76318-054
Facility: NYM
Unit: 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:

Rx# Medication
Docusate Sodium Capsule

Order Date

07/12/2019 09:06

Prescriber order TAKE ONE 100 MG CAP Orally Two Times a Day x 30 day(s)

Indication: Constipation, unspecified

Discontinued Medication Orders:
Rx# Medication

121757-NYM Bisacodyl E.C. 5 MG TAB

Order Date
07/12/2019 09:06

Prescriber Order
Take one tablet (5 MG) by mouth
at bedtime AS NEEDED for 10
days

Discontinue Type: When Pharmacy Processes
Discontinue Reason: discontinue
Indication:

Copay Required: No
Telephone/Verbal Order: No

Cosign Required: No

Completed by

on 07/12/2019 09:10

Generated 07/12/2019 09:10 by

Bureau of Prisons - NYM

Page 1 of 1

# CONFIDENTIAL

SDNY 00009426
EFTA00034957

# Bureau of Prisons
Health Services

# Clinical Encounter - Administrative Note

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Note Date: 07/07/2019 00:17

Sex: M Race: WHITE
Provider:

Reg #: 76318-054
Facility: NYM
Unit: E06

Cosign Note Intake Cosign encounter performed at Health Services. Administrative Notes:

ADMINISTRATIVE NOTE 1

MED CL:1
NO CCC APPT.

Provider:

# Clinical Encounter - Administrative Note (cont.)

<table><tr><th colspan="4">Discontinued Laboratory Requests:</th></tr><tr><td>Details</td><td>Frequency</td><td>Due Date</td><td>Priority</td></tr><tr><td>Lab Tests-H-Hemoglobin A1C</td><td>One Time</td><td>08/05/2019 00:00</td><td>Routine</td></tr><tr><td>Lab Tests-C-CBC w/diff</td><td></td><td></td><td></td></tr><tr><td>Lab Tests-L-Lipid Profile</td><td></td><td></td><td></td></tr><tr><td>Lab Tests-C-Comprehensive Metabolic Profile
(CMP)</td><td></td><td></td><td></td></tr><tr><td>Lab Tests-U-Urinalysis w/Reflex to Microscopic
Additional Information:</td><td></td><td></td><td></td></tr><tr><td>66 y/o male, elevated BP</td><td></td><td></td><td></td></tr><tr><td>Labs requested to be reviewed by:</td><td></td><td></td><td></td></tr><tr><td>New Laboratory Requests:</td><td></td><td></td><td></td></tr><tr><td>Details</td><td>Frequency</td><td>Due Date</td><td>Priority</td></tr><tr><td>Chronic Care Clinics-Diabetic-CBC w/diff</td><td>One Time</td><td>07/25/2019 00:00</td><td>Routine</td></tr><tr><td>Chronic Care Clinics-Diabetic-Lipid Profile</td><td></td><td></td><td></td></tr><tr><td>Chronic Care Clinics-Diabetic-Hemoglobin A1C</td><td></td><td></td><td></td></tr><tr><td>Lab Tests-H-HIV 1/2</td><td></td><td></td><td></td></tr><tr><td>Lab Tests-R-RPR</td><td></td><td></td><td></td></tr><tr><td>Chronic Care Clinics-Diabetic-Comprehensive</td><td></td><td></td><td></td></tr><tr><td>Metabolic Profile (CMP)</td><td></td><td></td><td></td></tr><tr><td>New Radiology Request Orders:</td><td></td><td></td><td></td></tr><tr><td>Details</td><td>Frequency End Date</td><td>Due Date</td><td>Priority</td></tr><tr><td>General Radiology-Chest-2 Views One</td><td>Time</td><td>07/25/2019</td><td>Routine</td></tr><tr><td colspan="4">Specific reason(s) for request (Complaints and findings):</td></tr><tr><td>66 YR OLD MALE WITH NO PMHX,</td><td>REFERRED FOR ROUITNE</td><td>CXR.</td><td></td></tr><tr><td>Copay Required: No Cosign</td><td>Required: No</td><td></td><td></td></tr><tr><td colspan="4">Telephone/Verbal Order: No</td></tr><tr><td>Completed by on 07/07/2019</td><td>00:30</td><td></td><td></td></tr></table>

# Clinical Encounter - Administrative Note (cont.)

Generated 07/07/2019 00:30 by

Bureau of Prisons - NYM

Page 1 of 1

# CONFIDENTIAL

SDNY 00009427
EFTA00034958

Bureau of Prisons
Health Services

# History & Physical

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/09/2019 12:35

Sex: M Race: WHITE
Provider:

Reg #:

Facility:

Unit:

76318-054

NYM
H01

# History & Physical (cont.)

<table><tr><th colspan="2">Encounter Date: 07/09/2019 12:35</th><th>Provider:</th><th>Unit: H01</th></tr><tr><td>Seizures:</td><td></td><td>Denied</td><td></td></tr><tr><td>Diabetes:</td><td></td><td>Denied</td><td></td></tr><tr><td>Cardiovascular:</td><td></td><td>Denied</td><td></td></tr><tr><td>CVA:</td><td></td><td>Denied</td><td></td></tr><tr><td>Hypertension:</td><td></td><td>Denied</td><td></td></tr><tr><td>Respiratory:</td><td></td><td>Denied</td><td></td></tr><tr><td>Sickle Cell Anemia:</td><td></td><td>Denied</td><td></td></tr><tr><td>Carcinoma/Lymphoma:</td><td></td><td>Denied</td><td></td></tr><tr><td>Allergies:</td><td></td><td>Denied</td><td></td></tr><tr><td>Tuberculosis:</td><td></td><td></td><td></td></tr><tr><td>Hx of Previous Disease: No</td><td></td><td></td><td></td></tr><tr><td>Blood-tinged Sputum: No</td><td></td><td></td><td></td></tr><tr><td>Night Sweats: No</td><td></td><td></td><td></td></tr><tr><td>Weight Loss: No</td><td></td><td></td><td></td></tr><tr><td>Fever: No</td><td></td><td></td><td></td></tr><tr><td>Cough: No</td><td></td><td></td><td></td></tr><tr><td>Comments:</td><td></td><td></td><td></td></tr><tr><td>Infectious Disease Risk Factors:</td><td></td><td></td><td></td></tr><tr><td>IV Drug Use: No</td><td></td><td></td><td></td></tr><tr><td>IV Drug Use Needles:</td><td></td><td></td><td></td></tr><tr><td>Sexual Partner IV Drug Use:</td><td>No</td><td></td><td></td></tr><tr><td>Sexual Partner IV Drug Use</td><td>Needles:</td><td></td><td></td></tr><tr><td>Female Sexual Partners (Last</td><td>5 Yrs):</td><td>10+</td><td></td></tr><tr><td>Male Sexual Partners (Last 5</td><td>Yrs):</td><td>0</td><td></td></tr><tr><td>Condom Use: Sometimes</td><td></td><td></td><td></td></tr><tr><td>Sexual Contact With HIV+</td><td>Individual:</td><td>No</td><td></td></tr><tr><td>Blood Product Transfusion:</td><td>No</td><td></td><td></td></tr><tr><td>Travel Outside US: Yes</td><td></td><td></td><td></td></tr><tr><td>Tattoos: No</td><td></td><td></td><td></td></tr><tr><td>Comments: Born in US</td><td></td><td></td><td></td></tr><tr><td>High school diploma</td><td></td><td></td><td></td></tr><tr><td>Banker</td><td></td><td></td><td></td></tr><tr><td>Traveled to Paris x</td><td>3</td><td>weeks up until arrest</td><td></td></tr><tr><td>No tattoos</td><td></td><td></td><td></td></tr></table>

# History & Physical (cont.)

Generated 07/09/2019 13:03 by





Bureau of Prisons - NYM

Page 1 of 13

CONFIDENTIAL

SDNY 00009428
EFTA00034959

# History & Physical (cont.)

Reg #: 76318-054

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/09/2019 12:35

Sex:
Provider:

M Race: WHITE

Facility: NYM
Unit: H01

<table><tr><th colspan="2">HIV History:</th></tr><tr><td>When Tested:</td><td>2019</td></tr><tr><td>Test Result:</td><td>Negative</td></tr><tr><td>When Diagnosed AIDS:</td><td></td></tr><tr><td>Last CD4:</td><td></td></tr><tr><td>Comments:</td><td></td></tr><tr><td>Hepatitis:</td><td>Denied</td></tr><tr><td>Other Infectious Diseases:</td><td></td></tr><tr><td>Syphilis:</td><td>No</td></tr><tr><td>Syphilis Last Treatment:</td><td>N/A</td></tr><tr><td>Genital Warts:</td><td>No</td></tr><tr><td>Chlamydia:</td><td>Yes</td></tr><tr><td>Gonorrhea:</td><td>No</td></tr><tr><td>Herpes:</td><td>No</td></tr><tr><td>Chicken Pox:</td><td>Yes</td></tr><tr><td>Other:</td><td>No</td></tr><tr><td colspan="2">Comments: Chlamydia in 2015, treated
Chicken pox in childhood</td></tr><tr><td>Abuse History: Denied</td><td></td></tr><tr><td>Physical: No</td><td></td></tr><tr><td>Emotional: No</td><td></td></tr><tr><td>Sexual: No</td><td></td></tr><tr><td>Comments: Denies</td><td></td></tr></table>

Generated 07/09/2019 13:03 by



Bureau of Prisons - NYM

Page 2 of 13

# CONFIDENTIAL

SDNY 00009429
EFTA00034960

# CONFIDENTIAL (cont.)

Reg #: 76318-054

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/09/2019 12:35

Sex:
Provider:

M Race: WHITE

Facility: NYM
Unit: H01

# CONFIDENTIAL (cont.)

<table><tr><th>Mental Health:</th></tr><tr><td>Level of Consciousness: Alert and Oriented</td></tr><tr><td>Psychomotor Activity: Normal</td></tr><tr><td>General Appearance: Normal</td></tr><tr><td>Behavior: Cooperative</td></tr><tr><td>Mood: Appropriate to Content</td></tr><tr><td>Thought Process: Goal Directed</td></tr><tr><td>Thought Content: Normal</td></tr><tr><td>Hx of Mental Health Treatment: None</td></tr><tr><td>Hx of Head Injury: None</td></tr><tr><td>Current Mental Health Treatment: No</td></tr><tr><td>Current Mental Health Complaint: No</td></tr><tr><td>Hx of Loss of Consciousness: No</td></tr><tr><td>Hx of Hearing Voices: No</td></tr><tr><td>Past History of Suicide Attempt: No</td></tr><tr><td>Current Suicide Ideation: No</td></tr><tr><td>Suicide Prevention Initiated: No</td></tr><tr><td>Comments:</td></tr><tr><td>Substance Use History: Denied</td></tr><tr><td>Current Painful Condition: Denied</td></tr><tr><td>Other Health Issues:</td></tr><tr><td>Current Medical Conditions:</td></tr><tr><td>Other Current Treatments:</td></tr><tr><td>Pregnant: N/A</td></tr><tr><td>Dental Condition: Denied</td></tr></table>

Generated 07/09/2019 13:03 by



Bureau of Prisons - NYM

Page 3 of 13

CONFIDENTIAL

SDNY 00009430
EFTA00034961

# CONFIDENTIAL (cont.)

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/09/2019 12:35

Sex:
Provider:

M Race: WHITE

Reg #: 76318-054
Facility: NYM
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:

Generated 07/09/2019 13:03 by|





Bureau of Prisons - NYM

Page 4 of 13

# CONFIDENTIAL

SDNY 00009431
EFTA00034962

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/09/2019 12:35

Sex:
Provider:

M Race: WHITE

Reg #: 76318-054
Facility: NYM
Unit: H01

# CONFIDENTIAL (cont.)

## Immunizations:

Hepatitis A and B (TwinRx) 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:

Measles/Mumps/Rubella 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:

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

CONFIDENTIAL

SDNY 00009432
EFTA00034963

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/09/2019 12:35

Sex:
Provider:

Rece: WHITE

Reg #: 76318-054
Facility: NYM
Unit: H01

Immunization Date:

# CONFIDENTIAL (cont.)

## Immunizations: (cont.)

<table><tr><th></th><th></th><th></th><th></th><th></th><th></th><th></th></tr><tr><td>Provider:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Location:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Drug Mfg:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Lot Number:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Dosage:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Route:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Exp Dt:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Comments:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="6">Varicella Series Administration: History Unknown, Not Administered</td><td></td></tr><tr><td>Documented</td><td>Date:</td><td>07/09/2019 12:51</td><td>EST</td><td></td><td></td><td></td></tr><tr><td>Immunization</td><td>Date:</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Provider:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Location:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Drug Mfg:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Lot Number:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Dosage:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Route:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Exp Dt:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Comments:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Temperature:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Date</td><td>Time</td><td>Fahrenheit</td><td>Celsius</td><td>Location</td><td>Provider</td><td></td></tr><tr><td>07/09/2019</td><td>12:49 NYM</td><td>97.3</td><td>36.3</td><td>Oral</td><td></td><td></td></tr><tr><td>Pulse:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Date</td><td>Time</td><td>Rate Per Minute</td><td></td><td>Location</td><td>Rhythm</td><td>Provider</td></tr><tr><td>07/09/2019</td><td>12:49</td><td></td><td>82 Via</td><td>Machine</td><td>Regular</td><td></td></tr><tr><td>Respirations:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Date</td><td>Time</td><td>Rate</td><td>Per Minute</td><td>Provider</td><td></td><td></td></tr><tr><td>07/09/2019</td><td>12:49</td><td>NYM</td><td>16</td><td></td><td></td><td></td></tr><tr><td>Blood Pressure:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Date</td><td>Time</td><td>Value Location</td><td></td><td>Position</td><td>Cuff Size</td><td>Provider</td></tr><tr><td>07/09/2019</td><td>12:49 NYM</td><td>117/66 Right</td><td>Arm</td><td>Sitting</td><td>Adult-regular</td><td>TH</td></tr><tr><td>SaO2:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Date</td><td>Time</td><td>Value(%) Air</td><td></td><td></td><td>Provider</td><td></td></tr><tr><td>07/09/2019</td><td>12:49 NYM</td><td>97</td><td>Room Air</td><td></td><td></td><td></td></tr><tr><td>Height:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Date</td><td>Time</td><td>Inches</td><td>Cm</td><td>Provider</td><td></td><td></td></tr><tr><td>07/09/2019</td><td>12:49 NYM</td><td>70.0</td><td>177.8</td><td></td><td></td><td></td></tr></table>

# CONFIDENTIAL (cont.)

## Immunizations: (cont.)

Generated 07/09/2019 13:03 by



Bureau of Prisons - NYM

Page 6 of 13

CONFIDENTIAL

SDNY 00009433
EFTA00034964

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/09/2019 12:35

Sex:
Provider:

M Race: WHITE

Reg #: 76318-054
Facility: NYM
Unit: H01

# CONFIDENTIAL (cont.)

## Immunizations: (cont.)

<table><tr><th>Date</th><th>Time Inches</th><th>Cm Provider</th><th></th></tr><tr><td>Weight:</td><td></td><td></td><td></td></tr><tr><td>Date</td><td>Time Lbs</td><td>Kg Waist Circum. Provider</td><td></td></tr><tr><td>07/09/2019</td><td>12:49 NYM 194.4</td><td>88.2</td><td></td></tr><tr><td colspan="2">Prosthetic Devices/Equipment: Denied</td><td></td><td></td></tr><tr><td colspan="2">Tobacco Usage: Denied</td><td></td><td></td></tr><tr><td colspan="2">General Social History:</td><td></td><td></td></tr><tr><td>Foreign Travel:</td><td></td><td></td><td></td></tr><tr><td>Born in USA:</td><td>Yes</td><td></td><td></td></tr><tr><td colspan="2">Country of Birth: USA</td><td></td><td></td></tr><tr><td colspan="2">Patient Education Assessments:</td><td></td><td></td></tr><tr><td>Date</td><td>Ed Yrs Occupation</td><td>Learns Best By Primary Language</td><td>Barriers to Education</td></tr><tr><td>07/09/2019</td><td>12 Banker</td><td>Speaking/Listening English</td><td>None</td></tr><tr><td colspan="2">Family History - Father:</td><td></td><td></td></tr><tr><td>Age at Death:</td><td>74</td><td></td><td></td></tr><tr><td>Cause of</td><td>Death: Diabetes complications</td><td></td><td></td></tr><tr><td>Significant</td><td>Illnesses:</td><td></td><td></td></tr><tr><td>Diabetes</td><td></td><td></td><td></td></tr><tr><td>Heart</td><td>Disease</td><td></td><td></td></tr><tr><td>Comments:</td><td></td><td></td><td></td></tr><tr><td>Family History</td><td>- Mother:</td><td></td><td></td></tr><tr><td>Age at Death:</td><td>81</td><td></td><td></td></tr><tr><td>Cause of</td><td>Death: Kidney Failure</td><td></td><td></td></tr><tr><td>Significant</td><td>Illnesses:</td><td></td><td></td></tr><tr><td>Heart</td><td>Disease</td><td></td><td></td></tr><tr><td>Comments:</td><td></td><td></td><td></td></tr><tr><td>Family History</td><td>- Sibling:</td><td></td><td></td></tr><tr><td>Number of</td><td>Siblings: 1</td><td></td><td></td></tr><tr><td>Significant</td><td>Illnesses:</td><td></td><td></td></tr><tr><td>Comments:</td><td></td><td></td><td></td></tr><tr><td>Past Hospitalization:</td><td></td><td></td><td></td></tr><tr><td>Reason</td><td></td><td>Location</td><td>When</td></tr><tr><td>Acute Appendicitis</td><td></td><td>Mount Sinai Hospital</td><td>1990</td></tr><tr><td>Complications:</td><td>None</td><td></td><td></td></tr><tr><td>Comments:</td><td></td><td></td><td></td></tr><tr><td>Head:</td><td></td><td></td><td></td></tr><tr><td>Normal: Yes</td><td></td><td></td><td></td></tr><tr><td>Comments:</td><td></td><td></td><td></td></tr></table>

# CONFIDENTIAL (cont.)

## Immunizations: (cont.)

Generaled 07/09/2019 13:03 by



Bureau of Prisons - NYM

Page 7 of 13

CONFIDENTIAL

SDNY 00009434
EFTA00034965

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/09/2019 12:35

Reg #:

76318-054
NYM
H01

M Race: WHITE

Sex:
Provider:

Facility:

Unit:

# CONFIDENTIAL (cont.)

## Immunizations: (cont.)

<table><tr><th colspan="5">Eyes:</th></tr><tr><td>EOMI: Yes</td><td></td><td></td><td></td><td></td></tr><tr><td>Icterus:No</td><td></td><td></td><td></td><td></td></tr><tr><td>Conjunctival Inflammation: No</td><td></td><td></td><td></td><td></td></tr><tr><td>Pupils PERRLA: Yes</td><td></td><td></td><td></td><td></td></tr><tr><td>Pupil Size Rt:</td><td></td><td></td><td></td><td></td></tr><tr><td>Pupil Size Lt:</td><td></td><td></td><td></td><td></td></tr><tr><td>Pupils Comments:</td><td></td><td></td><td></td><td></td></tr><tr><td>Fundi Vessels Nicking: No</td><td></td><td></td><td></td><td></td></tr><tr><td>Fundi Vessels Discs Flat:Yes</td><td></td><td></td><td></td><td></td></tr><tr><td>Fundi Vessels Discs Sharp Margins: Yes</td><td></td><td></td><td></td><td></td></tr><tr><td>Fundi Vessels Grounds Abnormal: No</td><td></td><td></td><td></td><td></td></tr><tr><td>Eyes Comments:</td><td></td><td></td><td></td><td></td></tr><tr><td>Vision Screen 07/09/2019 12:52</td><td></td><td></td><td></td><td></td></tr><tr><td>Blindness:</td><td></td><td>With</td><td>Corrective</td><td></td></tr><tr><td>Distance Vision: OD: 100 OS: 70</td><td>OU:</td><td>OD:</td><td>OS</td><td>OU:</td></tr><tr><td>Near Vision: OD: OS:</td><td>OU:</td><td>OD:</td><td>OS:</td><td>OU:</td></tr><tr><td>Ishihara Color Test:</td><td></td><td></td><td></td><td></td></tr><tr><td>Tonometry: L: R:</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="5">Comments: Needs evaluation with optometrist.</td></tr><tr><td>Ears:</td><td></td><td></td><td></td><td></td></tr><tr><td>Right Ear: Canal patent</td><td></td><td></td><td></td><td></td></tr><tr><td>Left Ear: Canal patent</td><td></td><td></td><td></td><td></td></tr><tr><td>Ears Comments:</td><td></td><td></td><td></td><td></td></tr><tr><td>Nose:</td><td></td><td></td><td></td><td></td></tr><tr><td>Nares Patent: Yes</td><td></td><td></td><td></td><td></td></tr><tr><td>Septum Midline: Yes</td><td></td><td></td><td></td><td></td></tr><tr><td>Septum Intact: Yes</td><td></td><td></td><td></td><td></td></tr><tr><td>Drainage/Discharge: No</td><td></td><td></td><td></td><td></td></tr><tr><td>Polyps: No</td><td></td><td></td><td></td><td></td></tr><tr><td>Nose Comments:</td><td></td><td></td><td></td><td></td></tr></table>

# CONFIDENTIAL (cont.)

## Immunizations: (cont.)

Generated 07/09/2019 13:03 by



Bureau of Prisons - NYM

Page 8 of 13

CONFIDENTIAL

SDNY 00009435
EFTA00034966

# CONFIDENTIAL (cont.)

## Immunizations: (cont.)

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/09/2019 12:35

Sex: M Race: WHITE
Provider:

Reg #: 76318-054

Facility: NYM
Unit: H01

<table><tr><th></th></tr><tr><td>Mouth</td></tr><tr><td>Lesions: No</td></tr><tr><td>Oral/Buccal Mucosa:Yes</td></tr><tr><td>Gums Normal: Yes</td></tr><tr><td>Tonsils Present: Yes</td></tr><tr><td>Tonsils Normal: Yes</td></tr><tr><td>Pharynx: Normal Color</td></tr><tr><td>Teeth Poor Dentition: No</td></tr><tr><td>Teeth Count:Mostly Present</td></tr><tr><td>Dentures: No</td></tr><tr><td>Mouth Comments:</td></tr><tr><td>Cranial Nerves:</td></tr><tr><td>Intact II-XII: Yes</td></tr><tr><td>Cranial Nerves Comments:</td></tr><tr><td>Neck:</td></tr><tr><td>Full ROM: Yes</td></tr><tr><td>Masses/Nodes: No</td></tr><tr><td>Trachea: Midline</td></tr><tr><td>Thyroid: Normal Size</td></tr><tr><td>Comments:</td></tr><tr><td>Breasts:</td></tr><tr><td>Normal: Yes</td></tr><tr><td>Masses:No</td></tr><tr><td>Tenderness:No</td></tr><tr><td>Scars: No</td></tr><tr><td>Dimpling:No</td></tr><tr><td>Nipple Discharge: No</td></tr><tr><td>Nipple Retraction: No</td></tr><tr><td>Instructions for Self Breast Exam Given: No</td></tr><tr><td>Comments:</td></tr></table>

# CONFIDENTIAL (cont.)

## Immunizations: (cont.)

Generated 07/09/2019 13:03 by





Bureau of Prisons - NYM

Page 9 of 13

# CONFIDENTIAL

SDNY 00009436
EFTA00034967