# Bureau of Prisons
Health Services
Clinical Encounter

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

Sex: M Race: WHITE
Provider: RN

Reg #: 76318-054
Facility: NYM
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 R hand still has pins and needles sometimes" No change in appearance from previous exam. Pain: No

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

## 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
EFTA00034929

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

## OBJECTIVE: (cont.)

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
Telephone/Verbal Order: No

Cosign Required: Yes

Completed by RN on 07/28/2019 20:30

Requested to be cosigned by 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
EFTA00034930

# Bureau of Prisons
Health Services
Cosign/Review

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

Sex: M

RN

Provider:

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

Cosigned by

MD on 07/28/2019 20:50.

Bureau of Prisons - NYM

# CONFIDENTIAL

SDNY 00009400
EFTA00034931

# Bureau of Prisons
Health Services
Clinical Encounter

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

Sex: M Race: WHITE
Provider: RN

Reg #: 76318-054
Facility: NYM
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

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

## 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
EFTA00034932

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

Sex:
Provider:

Reg #: 76318-054

M Race: WHITE

Facility: NYM

RN

Unit: H01

Exam:

No: Ecchymosis, Numbness, Swelling, Periorbital Edema

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

## OBJECTIVE: (cont.)

<table><tr><th>No: Ecchymosis, Numbness, Swelling, Periorbital Edema
Neck</th><th></th></tr><tr><td>General</td><td></td></tr><tr><td>Yes: Abrasion(s)</td><td></td></tr><tr><td>Pulmonary</td><td></td></tr><tr><td>Observation/Inspection</td><td></td></tr><tr><td>Yes: Within Normal Limits</td><td></td></tr><tr><td>No: Respiratory Distress, Tachypnea, Hyperventilation</td><td></td></tr><tr><td>Cardiovascular</td><td></td></tr><tr><td>Observation</td><td></td></tr><tr><td>Yes: Normal Rate</td><td></td></tr><tr><td>Musculoskeletal</td><td></td></tr><tr><td>Shoulder</td><td></td></tr><tr><td>Yes: Full Range of Motion R, Symmetric R</td><td></td></tr><tr><td>No: Swelling R, Inflammation R</td><td></td></tr><tr><td>Humerus</td><td></td></tr><tr><td>Yes: Within Normal Limits R</td><td></td></tr><tr><td>Elbow</td><td></td></tr><tr><td>Yes: Normal Exam R, Full Range of Motion R, Non-Tender on Palpation R</td><td></td></tr><tr><td>Radius / Ulna</td><td></td></tr><tr><td>Yes: Normal Exam R, Full Range of Motion R</td><td></td></tr><tr><td>Wrist/Hand/Fingers</td><td></td></tr><tr><td>Yes: Full Range of Motion R, Non-Tender on Palpation R, Swelling R</td><td></td></tr><tr><td>No: Inflammation R, Ecchymosis R, Erythema R, Tenderness R, Laceration(s) R, Abrasion(s)
Contusion(s) R</td><td>R,</td></tr></table>

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

## 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:

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

## 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

Provider Outcome
Verbalizes
Understanding

Generated 07/28/2019 07:22 by

RN

Bureau of Prisons - NYM

Page 2 of 3

CONFIDENTIAL

SDNY 00009402
EFTA00034933

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

Sex: M Race: WHITE
Provider: RN

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

Date Initiated Format Handout/Topic 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 MD.
Cosign documentation will be displayed on the following page.

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

Bureau of Prisons - NYM

Page 3 of 3

# CONFIDENTIAL

SDNY 00009403
EFTA00034934

# Bureau of Prisons
Health Services
Cosign/Review

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

Sex: M

Provider:

RN

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

Cosigned by

MD on 07/28/2019 20:51.

Bureau of Prisons - NYM

# CONFIDENTIAL

SDNY 00009404
EFTA00034935

Bureau of Prisons
Health Services

# Clinical Encounter - Administrative Note

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Note Date: 07/26/2019 08:57

Reg #: 76318-054

Sex: M Race: WHITE
Provider: 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# 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
Telephone/Verbal Order: No

Cosign Required: No

Completed by MD on 07/26/2019 08:58

Generated 07/26/2019 08:58 by

MD

Bureau of Prisons - NYM

Page 1 of 1

# CONFIDENTIAL

SDNY 00009405
EFTA00034936

Bureau of Prisons
Health Services

# Clinical Encounter - Administrative Note

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Note Date: 07/24/2019 16:10

Sex: M Race: WHITE
Provider: MD

Reg #: 76318-054

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.

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 00009406
EFTA00034937

# Bureau of Prisons
Health Services

# Clinical Encounter - Administrative Note

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953 Sex: M Race: WHITE
Note Date: 07/24/2019 16:10 Provider: MD

Reg#: 76318-054
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.

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
EFTA00034938

# Bureau of Prisons
Health Services

# See Amendment

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/26/2019 08:57

Sex:

M

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

Amendment made to this note by

MD on 07/26/2019 08:58.

Bureau of Prisons - NYM

# CONFIDENTIAL

SDNY 00009408
EFTA00034939

# Bureau of Prisons
Health Services

# Clinical Encounter - Administrative Note

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Note Date: 07/24/2019 15:10

Reg #:

Sex: M Race WHITE
Provider: MD

Facility:

Unit:

76318-054
NYM
H01

Admin Note General Administrative Note encounter performed at Health Services. Administrative Notes:

ADMINISTRATIVE NOTE 1 Provider: 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

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
EFTA00034940

# Bureau of Prisons
Health Services

# Clinical Encounter

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

Sex: M Race: WHITE
Provider:

Reg #: 76318-054
Facility: NYM
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:

# Clinical Encounter (cont.)

## OBJECTIVE: (cont.)

<table><tr><th>Date</th><th>Time</th><th>Fahrenheit</th><th>Celsius</th><th>Location</th><th>Provider</th><th></th></tr><tr><td>07/24/2019</td><td>13:12 NYM</td><td>97.8</td><td>36.6</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>07/24/2019</td><td>13:12</td><td></td><td>83</td><td>Via Machine</td><td>Regular</td><td></td></tr><tr><td colspan="2">Blood Pressure:</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>07/24/2019</td><td>13:12 NYM</td><td>132/89 Right</td><td>Arm</td><td>Sitting</td><td>Adult-regular</td><td></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(%)</td><td>Air</td><td></td><td>Provider</td><td></td></tr><tr><td>07/24/2019</td><td>13:12 NYM</td><td>96</td><td>Room Air</td><td></td><td></td><td></td></tr><tr><td>Exam:</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>General</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Affect</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes:</td><td>Cooperative</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="4">Appearance</td><td></td><td></td><td></td></tr><tr><td colspan="4">Yes: Appears Well, Alert and Oriented x 3</td><td></td><td></td><td></td></tr><tr><td>No:</td><td>Appears</td><td>Distressed, Appears</td><td>in Pain</td><td></td><td></td><td></td></tr></table>

# Clinical Encounter (cont.)

## 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



Bureau of Prisons - NYM

Page 1 of 2

CONFIDENTIAL

SDNY_00009410
EFTA00034941

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

Patient Education Topics:

Date Initiated Format
07/24/2019 Counseling

Handout/Topic
Access to Care

07/24/2019 Counseling

Preventive Health

Provider Outcome
Verbalizes
Understanding
Verbalizes
Understanding

Copay Required: No

Cosign Required: Yes

Telephone/Verbal Order: No

Completed by

on 07/24/2019 13:24

Requested to be cosigned by

MD.

Cosign documentation will be displayed on the following page.

Generated 07/24/2019 13:24 by

Bureau of Prisons - NYM

Page 2 of 2

# CONFIDENTIAL

SDNY 00009411
EFTA00034942

# Bureau of Prisons
Health Services
Cosign/Review

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

Sex:
Provider:

M

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

Cosigned with New Encounter Note by

MD on 07/24/2019 16:10.

Bureau of Prisons - NYM

# CONFIDENTIAL

SDNY 00009412
EFTA00034943

# Bureau of Prisons
Health Services
Clinical Encounter

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

Sex:
Provider:

M Race: WHITE

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

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

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

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

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

Pulse:

Date Time Rate Per Minute Location Rhythm Provider
07/23/2019 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 Cuff Size Provider
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

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

Bureau of Prisons - NYM

Page 1 of 2

CONFIDENTIAL

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

SDNY 00009413
EFTA00034944

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

Sex:
Provider:

M Race: WHITE

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

Exam:

Acutely III
Pulmonary
Auscultation
Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally
No: Crackles, Rhonchi, Wheezing

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

## 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

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

## Other:

For follow up with psychology service.

Patient Education Topics:

Date Initiated Format
07/23/2019 Counseling

Handout/Topic
Access to Care

Provider Outcome
Verbalizes
Understanding

Verbalizes
Understanding

07/23/2019 Counseling

Plan of Care

Copay Required: No

Cosign Required: Yes

Telephone/Verbal Order: No

Completed by

on 07/23/2019 09:05

Requested to be cosigned by

MD.

Cosign documentation will be displayed on the following page.

Generated 07/23/2019 09:05 by

Bureau of Prisons - NYM

Page 2 of 2

CONFIDENTIAL

SDNY 00009414
EFTA00034945

# Bureau of Prisons
Health Services

Cosign/Review

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

Sex: M
Provider:



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

Cosigned by

MD on 07/23/2019 15:44.

Bureau of Prisons - NYM

# CONFIDENTIAL

SDNY 00009415
EFTA00034946

# Bureau of Prisons
Health Services
Clinical Encounter

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

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

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

<table><tr><th>COMPLAINT 1</th><th>Provider: MD</th></tr><tr><td colspan="2">Chief Complaint: ENDO/LIPID</td></tr><tr><td colspan="2">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</td></tr><tr><td>Pain: Yes</td><td></td></tr><tr><td colspan="2">Pain Assessment</td></tr><tr><td>Date:</td><td>07/12/2019 13:25</td></tr><tr><td>Location:</td><td>Back-Middle</td></tr><tr><td>Quality of Pain:</td><td>Shooting</td></tr><tr><td>Pain Scale:</td><td>5</td></tr><tr><td>Intervention:</td><td>MEDROL DOSE PACK</td></tr><tr><td>Trauma Date/Year:</td><td></td></tr><tr><td>Injury:</td><td></td></tr><tr><td>Mechanism:</td><td></td></tr><tr><td>Onset:</td><td>5+ Years</td></tr><tr><td>Duration:</td><td>5+ Years</td></tr><tr><td>Exacerbating Factors:</td><td>NO EXERCISE</td></tr><tr><td>Relieving Factors:</td><td>MEDROL DOSE PACK</td></tr><tr><td>Reason Not Done:</td><td></td></tr><tr><td>Comments:</td><td></td></tr></table>

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

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 07/14/2019 18:11 by

MD

Bureau of Prisons - NYM

Page 1 of 3

CONFIDENTIAL

SDNY 00009416
EFTA00034947

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

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

## OBJECTIVE: (cont.)

Exam:

<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></table>

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

## PLAN:

New Medication Orders:

Rx#

Medication
Omega 3 (Vascepa) 1 GM Capsule

Order Date

07/14/2019 17:36

Prescriber Order
TAKE 2 CAPS Orally - Two
Times a Day x 180 day(s) -
TAKE WITH FOOD.

Indication: Hyperlipidemia, unspecified

New Laboratory Requests:

Details
Lab Tests-H-Hemoglobin A1C
Lab Tests-L-Lipid Profile
Additional Information:

Frequency
One Time

Due Date
10/10/2019 00:00

Priority
Routine

Generated 07/14/2019 18:11 by

MD

Bureau of Prisons - NYM

Page 2 of 3

CONFIDENTIAL

SDNY 00009417
EFTA00034948

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

Sex:
Provider:

M Race: WHITE

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

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

## PLAN: (cont.)

<table><tr><th>Encounter Date: 07/14/2019 17:36</th><th></th><th>Provider:</th><th>MD Unit:</th><th>Z05</th><th></th></tr><tr><td>FASTING.</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Lab Tests-H-Hep B surface Ab</td><td></td><td>One Time</td><td>08/08/2019 00:00</td><td>Routine</td><td></td></tr><tr><td>Lab Tests-H-Hep B surface Ag</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Lab Tests-H-Hep C Ab</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Lab Tests-H-Hepatic Profile</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Schedule:</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Activity</td><td></td><td>Date Scheduled</td><td>Scheduled Provider</td><td></td><td></td></tr><tr><td>Clinical Encounter</td><td></td><td>07/24/2019 00:00</td><td>Optometrist</td><td></td><td></td></tr><tr><td colspan="3">66 YR OLD MALE FOR ROUTINE SCREENING.</td><td></td><td></td><td></td></tr><tr><td>Chronic Care Visit
6 MONTH F/U.</td><td></td><td>01/07/2020 00:00</td><td>Mid-Level Provider</td><td></td><td></td></tr><tr><td>Chronic Care Visit</td><td></td><td>07/01/2020 00:00</td><td>Physician 01</td><td></td><td></td></tr><tr><td>Other:</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="3">PENDING EKG AND FOBT. CXR WAS REFUSED.</td><td></td><td></td><td></td></tr><tr><td>Patient Education Topics:</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Date Initiated Format</td><td></td><td>Handout/Topic</td><td>Provider</td><td></td><td>Outcome</td></tr><tr><td>07/14/2019 Counseling</td><td></td><td>Diagnosis</td><td></td><td></td><td>Verbalizes
Understanding</td></tr><tr><td>Copay Required: No</td><td>Cosign</td><td>Required: No</td><td></td><td></td><td></td></tr><tr><td>Telephone/Verbal Order: No</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Completed by</td><td>MD on 07/14/2019</td><td>18:11</td><td></td><td></td><td></td></tr></table>

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

## PLAN: (cont.)

Generated 07/14/2019 18:11 by

MD

Bureau of Prisons - NYM

Page 3 of 3

# CONFIDENTIAL

SDNY 00009418
EFTA00034949