# Bureau of Prisons
Health Services
Clinical Encounter

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054

Date of Birth: 01/20/1953
Sex: M 
Race: WHITE
Facility: NYM

Encounter Date: 07/28/2019 20:25
Provider: RN
Unit: H01

Nursing - Follow up encounter performed at Health Services.

## SUBJECTIVE:

COMPLAINT 1
Provider: <empty> 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 R hand still has pins and needles sometimes" No change in appearance from previous exam.
Pain: No

## OBJECTIVE:

Pulse:
Date Time Rate Per Minute Location Rhythm Provider
07/28/2019 20:28 81 RN

Respirations:
Date Time Rate Per Minute Provider
07/28/2019 20:28 NYM 14 RN

Blood Pressure:
Date Time Value Location Position Cuff Size Provider
07/28/2019 20:28 NYM 157/91 RN

SaO2:
Date Time Value(%) Air Provider
07/28/2019 20:28 NYM 98 RN

## 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 07/28/2019 20:30 by RN

Bureau of Prisons - NYM

Page 1 of 2

CONFIDENTIAL

SDNY 00009398
EFTA00033804

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/28/2019 20:25

Sex:
Provider:

M Race: WHITE
RN

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

Follow-up in 12-24 Hours

Patient Education Topics:

Date Initiated Format

07/28/2019

Counseling

Handout/Topic: Plan of Care

Provider

Outcome
Verbalizes
Understanding

Copay Required: No
Cosign Required: Yes

Telephone/Verbal Order: No

Completed by <empty> RN on 07/28/2019 20:30
Requested to be cosigned by <empty> MD.

Cosign documentation will be displayed on the following page.

Generated 07/28/2019 20:30 by RN

Bureau of Prisons - NYM

Page 2 of 2

CONFIDENTIAL

SDNY 00009399
EFTA00033805

# Bureau of Prisons
Health Services
Cosign/Review

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054

Date of Birth: 01/20/1953 
Sex: M
Race: WHITE

Encounter Date: 07/28/2019 20:25
Provider: RN
Facility: NYM

Cosigned by MD on 07/28/2019 20:50.

Bureau of Prisons • NYM

CONFIDENTIAL

SDNY 00009400
EFTA00033806

# Bureau of Prisons
Health Services
Clinical Encounter

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054

Date of Birth: 01/20/1953
Sex: M 
Race: WHITE
Facility: NYM

Encounter Date: 07/28/2019 06:51
Provider: RN
Unit: H01

Nursing - Triage Note encounter performed at Health Services.

## SUBJECTIVE:

COMPLAINT 1
Provider: <empty> 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:
Date Time Rate Per Minute Location Rhythm Provider
07/28/2019 06:57 82 RN

Respirations:
Date Time Rate Per Minute Provider
07/28/2019 06:57 NYM 14 RN

Blood Pressure:
Date Time Value Location Position Cuff Size Provider
07/28/2019 06:57 NYM 138/80 RN

SaO2:
Date Time Value(%) Air Provider
07/28/2019 06:57 NYM 98 RN

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, Atraumatic/Normocephalic
No: Facial Asymmetry, Battle's Sign, Raccoon Eyes, Deformity
Eyes
General
Yes: PERRLA, Extraocular Movements Intact
Face
General
Yes: Symmetric
Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM

Page 1 of 3

CONFIDENTIAL

SDNY 00009401

EFTA00033807

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054

Date of Birth: 01/20/1953
Sex: M 
Race: WHITE
Facility: NYM

Encounter Date: 07/28/2019 06:51
Provider: 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 R, Symmetric R

No: Swelling R, Inflammation R

## Humerus

Yes: Within Normal Limits R

Elbow

Yes: Normal Exam R, Full Range of Motion R, Non-Tender on Palpation R

Radius / Ulna

Yes: Normal Exam R, Full Range of Motion R

## Wrist/Hand/Fingers

Yes: Full Range of Motion R, Non-Tender on Palpation R, Swelling R

No: Inflammation R, Ecchymosis R, Erythema R, Tenderness R, Laceration(s) R, Abrasion(s) R, Contusion(s) R

## 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. V/S 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 any pain numbness or tingling at this time. Denies any Chest pain, Headache, Dizziness, SOB or Blurred vision. Eyes PERRLA. 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:

Date Initiated Format
07/28/2019 Counseling

Handout/Topic: Plan of Care
Bureau of Prisons - NYM

Provider

Generated 07/28/2019 07:22 by RN

Outcome
Verbalizes
Understanding

Page 2 of 3

CONFIDENTIAL

SDNY 00009402
EFTA00033808

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/28/2019 06:51

Sex:
Provider:

M Race: WHITE
RN

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

Date Initiated Format Handout/Topic
Copay Required: No Cosign Required: Yes
Telephone/Verbal Order: No
Completed by RN on 07/28/2019 07:22
Requested to be cosigned by MD.
Cosign documentation will be displayed on the following page.

Provider

Outcome

Generated 07/28/2019 07:22 by Columbo Joseph RN

Bureau of Prisons - NYM

Page 3 of 3

CONFIDENTIAL

SDNY_00009403
EFTA00033809

# Bureau of Prisons
Health Services
Cosign/Review

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054

Date of Birth: 01/20/1953 
Sex: M
Race: WHITE

Encounter Date: 07/28/2019 06:51
Provider: RN
Facility: NYM

Cosigned by MD on 07/28/2019 20:51.

Bureau of Prisons • NYM

CONFIDENTIAL

SDNY 00009404
EFTA00033810

# Bureau of Prisons

# Health Services

# Clinical Encounter - Administrative Note

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054

Date of Birth: 01/20/1953
Sex: M 
Race: WHITE

Note Date: 07/26/2019 08:57
Provider: <empty> MD

Facility: NYM
Unit: H01

Cosign Note - Clinical Encounter Cosign encounter performed at Health Services.
Administrative Notes:
ADMINISTRATIVE NOTE 1 Provider: MD
THE NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO.

New Medication Orders:
Rx#: <empty>
Medication: Docusate Sodium Capsule

Order Date: 07/26/2019 08:57

Prescriber Order
TAKE ONE 100 MG CAP Orally
- Two Times a Day x 180 day(s)

Indication: Constipation, unspecified

Copay Required:No
Cosign Required: No
Telephone/Verbal Order: No
Completed by <empty> MD on 07/26/2019 08:58

Generated 0726/2019 08.58 by

MD MD

Bureau of Prisons - NYM

Page 1 of 1

CONFIDENTIAL

SDNY 00009405

EFTA00033811

Bureau of Prisons

Health Services

Clinical Encounter - Administrative Note

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054

Date of Birth: 01/20/1953
Sex: M 
Race: WHITE
Facility: NYM

Note Date: 07/24/2019 16:10
Provider: <empty> MD
Unit: H01

Cosign Note - Clinical Encounter Cosign encounter performed at Health Services.

Administrative Notes:

ADMINISTRATIVE NOTE 1 
Provider: MD
THE NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO.

Copay Required: No

Telephone/Verbal Order: No

Completed by Beaudouin, Robert MD on 07/24/2019 16:12

Cosign Required: No
See Amendment

Generated 07/24/2019 16:12 by MD

Bureau of Prisons - NYM

Page 1 of 1

CONFIDENTIAL

SDNY 00009406
EFTA00033812

Bureau of Prisons

Health Services

Clinical Encounter - Administrative Note

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054

Date of Birth: 01/20/1953
Sex: M 
Race: WHITE
Facility: NYM

Note Date: 07/24/2019 16:10
Provider: <empty> MD
Unit: H01

Cosign Note - Clinical Encounter Cosign encounter performed at Health Services.

Administrative Notes:

ADMINISTRATIVE NOTE 1 
Provider: MD
THE NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO.

Copay Required: No Cosign Required: No
Telephone/Verbal Order: No
Completed by Beaudouin, Robert MD on 07/24/2019 16:12

See Amendment

Generated 07/24/2019 16:12 by MD

Bureau of Prisons - NYM

Page 1 of 1

CONFIDENTIAL

SDNY_00009407

EFTA00033813

# Bureau of Prisons
Health Services
See Amendment

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054
Date of Birth: 01/20/1953 
Sex: M
Race: WHITE
Encounter Date: 07/26/2019 08:57
Facility: NYM

Amendment made to this note by MD on 07/26/2019 08:58.

Bureau of Prisons - NYM

CONFIDENTIAL

SDNY 00009408

EFTA00033814

# Bureau of Prisons

# Health Services

# Clinical Encounter - Administrative Note

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054

Date of Birth: 01/20/1953
Sex: M 
Race: WHITE
Facility: NYM

Note Date: 07/24/2019 15:10
Provider: <empty> MD
Unit: H01

Admin Note - General Administrative Note encounter performed at Health Services.
Administrative Notes:
ADMINISTRATIVE NOTE 1 Provider: MD

ADMINISTRATIVE NOTE 1 
Provider: <empty> MD
PATIENT WAS OFFERED TO HAVE AN OPTOMETRIST EVALUATION. HE REFUSED. REFUSAL FORM SIGNED.

Copay Required:No
Cosign Required: No
Telephone/Verbal Order: No
Completed by <empty> MD on 07/24/2019 15:17

Generated 07/24/2019 15:17 by MD

Bureau of Prisons • NYM

Page 1 of 1

CONFIDENTIAL

SDNY 00009409
EFTA00033815

# Bureau of Prisons
Health Services
Clinical Encounter

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054

Date of Birth: 01/20/1953 
Sex: M 
Race: WHITE
Facility: NYM

Encounter Date: 07/24/2019 13:08
Provider: <empty>
Unit: H01

Mid Level Provider - Follow up Visit encounter performed at Receiving & Discharge.

SUBJECTIVE:

COMPLAINT 1
Provider: <empty>
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 Time Fahrenheit Celsius Location Provider
07/24/2019 13:12 NYM 97.8 36.6 Oral <empty>

## Pulse:

Date Time Rate Per Minute Location Rhythm Provider
07/24/2019 13:12 83 Via Machine Regular <empty>

Blood Pressure:

Date Time Value Location Position Cuff Size Provider
07/24/2019 13:12 NYM 132/89 Right Arm Sitting Adult-regular

## SaO2:

Date: 07/24/2019
Time: 13:12 NYM
Value(%) Air Provider
96 Room Air <empty>

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 mate. But does not want to talk about it.

## ASSESSMENT:

Injury, unspecified, T1490 - Current

PLAN:

## Disposition:

Generated 07/24/2019 13:24 by [REDACTED] Bureau of Prisons - NYM Page 1 of 2

CONFIDENTIAL

SDNY_00009410
EFTA00033816

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/24/2019 13:08

Sex:
Provider:

M Race: WHITE

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

Follow-up at Sick Call as Needed

<table><tr><th colspan="4">Patient Education Topics:</th></tr><tr><td>Pate Initiated</td><td>format </td><td></td><td>Handout/Topic </td></tr><tr><td>07/24/2019</td><td>Counseling</td><td></td><td>Access to Care</td></tr><tr><td>07/24/2019</td><td>Counseling</td><td></td><td>Preventive Health</td></tr><tr><td>Copay Required:No</td><td></td><td>Cosign</td><td>Required: Yes</td></tr><tr><td colspan="4">TelephoneNerbal Order: No</td></tr><tr><td>Completed by</td><td></td><td>on 07/24/2019</td><td>13:24</td></tr><tr><td>Requested to be</td><td>cosigned by</td><td></td><td>MD.</td></tr><tr><td colspan="4">Cosign documentation will be displayed on the following page.</td></tr></table>

Patient Education Topics:
Date Initiated Format Handout/Topic Provider Outcome
07/24/2019 Counseling Access to Care <empty> Verbalizes Understanding
07/24/2019 Counseling Preventive Health <empty> Verbalizes Understanding

Generated 07/24/2019 13:24 by

Bureau of Prisons • NYM

Page 2 of 2

CONFIDENTIAL

SDNY 00009411
EFTA00033817

Bureau of Prisons
Health Services
Cosign/Review

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054

Date of Birth: 01/20/1953 
Sex: M
Race: WHITE

Encounter Date: 07/24/2019 13:08
Provider: <empty>
Facility: NYM

Cosigned with New Encounter Note by MD on 07/24/2019 16:10.

Bureau of Prisons - NYM

CONFIDENTIAL

SDNY 00009412
EFTA00033818

# Bureau of Prisons
Health Services
Clinical Encounter

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054

Date of Birth: 01/20/1953
Sex: M 
Race: WHITE
Facility: NYM

Encounter Date: 07/23/2019 06:20
Provider: <empty>
Unit: H01

Injury Assessment - Non-work related encounter performed at Health Services.

## SUBJECTIVE:

INJURY 1 Provider: <empty>
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

OBJECTIVE:
Temperature:
Date: 07/23/2019
Time: 06:30 NYM
Fahrenheit: 97.5
Celsius: 36.4
Location: Oral
Provider: <empty>

Pulse:
Date: 07/23/2019
Time: 06:30
Rate Per Minute: 92
Location: Via Machine
Rhythm: Regular
Provider: <empty>

Respirations:
Date: 07/23/2019
Time: 06:30 NYM
Rate Per Minute: 16
Provider: <empty>

Blood Pressure:
Date: 07/23/2019
Time: 06:30 NYM
Value: 140/85
Location: Right Arm
Position: Sitting
Cuff Size: Adult-regular
Provider: <empty>

SaO2:
Date: 07/23/2019
Time: 06:30 NYM
Value(%): 96
Air: Room Air
Provider: <empty>

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 07/23/2019 09:05 by <signature>
Bureau of Prisons - NYM
Page 1 of 2

CONFIDENTIAL

SDNY 00009413

EFTA00033819

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/23/2019 06:20

Sex: M Race: WHITE
Provider:

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

Exam:
Acutely Ill
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:
Injury, unspecified, T1490 - Current - R/O self inflicted injuries.

PLAN:

## Disposition:

Follow-up at Sick Call as Needed
Placed on Suicide Watch
Follow-up in 2-4 Hours

Other:
For follow up with psychology service.

<table><tr><th>Patient Education Topics:</th><th></th><th></th><th></th></tr><tr><td>Date Initiated Format</td><td>Handout/Tooic</td><td>Provider</td><td>Outcome</td></tr><tr><td>07/23/2019 Counseling</td><td>Access to Care</td><td></td><td>Verbalizes </td></tr><tr><td></td><td></td><td></td><td>Understanding </td></tr><tr><td>07/23/2019 Counseling</td><td>Plan of Care</td><td></td><td>Verbalizes 
Understanding </td></tr><tr><td>Copay Required:No</td><td>Cosign Required: Yes</td><td></td><td></td></tr><tr><td>TelephoneNerbal Order: No</td><td></td><td></td><td></td></tr><tr><td colspan="3">Completed by . on 07/23/2019 09:05</td><td></td></tr><tr><td>Requested to be cosigned by</td><td>MD.</td><td></td><td></td></tr><tr><td colspan="4">Cosign documentation will be displayed on the following page.</td></tr></table>

Generated 07/23/2019 09:05 by

Bureau of Prisons - NYM

Page 2 of 2

CONFIDENTIAL

SDNY 00009414
EFTA00033820

Bureau of Prisons
Health Services
Cosign/Review

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054

Date of Birth: 01/20/1953 
Sex: M
Race: WHITE

Encounter Date: 07/23/2019 06:20
Provider: <empty>
Facility: NYM

Cosigned by MD on 07/23/2019 15:44.

Bumau of Prisons - NYM

CONFIDENTIAL

SDNY 00009415
EFTA00033821

# Bureau of Prisons
Health Services
Clinical Encounter

Inmate Name: EPSTEIN, JEFFREY EDWARD
Reg #: 76318-054

Date of Birth: 01/20/1953
Sex: M 
Race: WHITE
Facility: NYM

Encounter Date: 07/14/2019 17:36
Provider: <empty> MD
Unit: Z05

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

## SUBJECTIVE:

| COMPLAINT   | 1   | Provider:   | MD   |
|-|-|-|-|

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 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   |
|-|-|
| 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:             |                    |

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 Ill
Nutrition
No: Appears Obese

Generated 07/14/2019 18:11 by <empty> MD
Bureau of Prisons - NYM
Page 1 of 3

CONFIDENTIAL

SDNY 00009416

EFTA00033822

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

Sex: M Race: WHITE
Provider: MD

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

<table><tr><th>Exam:</th></tr><tr><td>Eyes</td></tr><tr><td>General</td></tr><tr><td>Yes: PERRLA, Extraocular Movements Intact</td></tr><tr><td>Pulmonary</td></tr><tr><td>Auscultation</td></tr><tr><td>Yes: Clear to Auscultation</td></tr><tr><td>Cardiovascular</td></tr><tr><td>Auscultation</td></tr><tr><td>Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2</td></tr><tr><td>No: M/R/G</td></tr><tr><td>Abdomen</td></tr><tr><td>Auscultation</td></tr><tr><td>Yes: Normo-Active Bowel Sounds</td></tr><tr><td>Palpation</td></tr><tr><td>Yes: Within Normal Limits</td></tr><tr><td>Musculoskeletal</td></tr><tr><td>Tibia / Fibula</td></tr><tr><td>No: Edema</td></tr><tr><td>Back</td></tr><tr><td>Yes: Tenderness</td></tr><tr><td>Neurologic</td></tr><tr><td>Cranial Nerves (CN)</td></tr><tr><td>Yes: Within Normal Limits</td></tr><tr><td>Motor System-General</td></tr><tr><td>Yes: Normal Exam</td></tr><tr><td>ASSESSMENT:</td></tr><tr><td>Constipation, unspecified, K5900 - Current</td></tr><tr><td>Hyperlipidemia, unspecified, E785 - Current</td></tr><tr><td>Low back pain, M545 - Current</td></tr><tr><td>Neuralgia and neuritis, unspecified, M792 - Current</td></tr><tr><td>Sleep apnea, G4730 - Current</td></tr><tr><td>PLAN:</td></tr><tr><td>New Medication Orders:</td></tr><tr><td>mt Medication Order Date Prescriber Order</td></tr><tr><td>Omega 3 ( Vascepa) 1 GM Capsule 07/14/2019 17:36 TAKE 2 CAPS Orally - Two
Times a Day x 180 day(s) —
TAKE WITH</td></tr><tr><td>FOOD.
Indication: Hyperlipidemia, unspecified</td></tr><tr><td>New Laboratory Requests:</td></tr><tr><td>Details Frequency rilictPata Priority</td></tr><tr><td>Lab Tests-H-Hemoglobin A1C One Time 10/10/2019 00:00 Routine</td></tr><tr><td>Lab Tests-L-Lipid Profile</td></tr><tr><td>Additional Information:</td></tr><tr><td>Generated 07/14/2019 18:11 by  MD  Bureau of Prisons - NYM Page 2 of 3</td></tr></table>

CONFIDENTIAL

SDNY 00009417
EFTA00033823

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

Sex:
Provider:

M Race: WHITE
MD

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

FASTING.
Lab Tests-H-Hep B surface Ab One Time 08/08/2019 00:00 Routine
Lab Tests-H-Hep B surface Ag
Lab Tests-H-Hep C Ab
Lab Tests-H-Hepatic Profile

## Schedule:

| Activity                              | Date Scheduled                        | Scheduled Provider   |
|-|-|-|
| Clinical Encounter                    | 07/24/2019 00:00                      | Optometrist          |
| 66 YR OLD MALE FOR ROUTINE SCREENING. | 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:   | Patient Education Topics:   | Patient Education Topics:   |
|-|-|-|
| Pate InitiatedFormat        |                             | Handout/Tonic               |
| 07/14/2019                  | Counseling                  | Diagnosis                   |
| Copay Required:No           | Copay Required:No           | Cosign Required: No         |
| TelephoneNerbal Order: No   | TelephoneNerbal Order: No   |                             |
| Completed by                |                             | MD on 07/14/2019 18:11      |

Provider

Outcome 
Verbalizes 
Understanding

Generated 07/14/2019 18:11 by MD

Bureau of Prisons NYM -

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CONFIDENTIAL

SDNY 00009418
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